Preamble

The House met at half-past Two o'clock

PRAYERS

[MADAM SPEAKER in the Chair]

Oral Answers to Questions — HOME DEPARTMENT

The Secretary of State was asked—

Europol

Shona McIsaac: What assessment he has made of the effectiveness of Europol in combating organised crime. [85564]

The Parliamentary Under-Secretary of State for the Home Department (Kate Hoey): Europol is already providing valuable support to member states in their efforts to tackle organised crime. Its role will become even more important when it takes up its full range of activities, which we hope will be on 1 July.

Shona McIsaac: I thank my hon. Friend for that answer. Will she explain the particular role that Europol will play in the fight against drug trafficking? Does she acknowledge that we need the co-operation of European Union member states if we are to be successful in that fight against drugs, and that we shall never be successful if we go it alone?

Kate Hoey: My hon. Friend is absolutely right. The fight against organised criminals who trade in drugs is an

extremely important task for Europol, as it was for Europol's precursor, the Europol drugs unit. Recently, there have been some very successful operations in which, as a result of intelligence from the Europol liaison officers, about 207 kg of cocaine was seized in Spain. Europol will be able to do a most important job, which will mean that our streets will be safer and that fewer people will suffer as a result of drugs going into our constituencies.

Mr. John Greenway: Chastened by her party's drubbing in the European elections, when people voted to be in Europe, not run by Europe, does the hon. Lady acknowledge the constructive role of the previous Conservative Government in the creation of Europol, and that the success to which she has just referred is based on co-operation between member Governments? Is it not true that the worst possible development for Europol would be to bring it and the criminal justice system into the competence of the European Commission—a discredited commission that cannot even deal with fraud in its own affairs?

Kate Hoey: It is correct that the previous Government played a most important role in the setting up of Europol, as the hon. Gentleman points out. The United Kingdom was the first country to sign the Europol convention. We are absolutely clear that Europol's powers will be operative, not operational; its staff will not have powers to arrest people or to initiate investigations independently, nor will they operate in the territory of member states, except in a support capacity. In view of that, we can all support the work that Europol will do to make our country safer from criminals—particularly from organised criminals.

Identity Cards

Mr. Dale Campbell-Savours: If he will make a statement on the Government's policy towards the use of identity cards. [85565]

The Secretary of State for the Home Department (Mr. Jack Straw): I see no arguments to convince me in favour of compulsory identity cards whereby a failure to carry a card in a public place would become a criminal offence. Subject to that caveat, we keep under review the balance of advantages and disadvantages that national identity cards could bring.

Mr. Campbell-Savours: My right hon. Friend will know that there is wide support among the general public not only for the introduction of compulsory cards, but for voluntary cards to be used as an interim measure. Why does he not now put that matter out for national consultation, through our access to local authorities, to the police and to Departments of State and also by using focus groups, in order to establish the demand and with a view to the early introduction of that excellent system?

Mr. Straw: Experience in other countries, particularly in Australia, shows that, although the public concerned may, in theory, be in favour of a compulsory card, when they are faced with the consequences of compulsion—namely, that it becomes a criminal offence not to have a card with them—there is immediately the potential for substantial and gratuitous conflict between the police and individual members of the public whose crime has been to forget their wallet. At that point, support for a compulsory card tends to wither away rather rapidly. I am open to argument over the matter, but I see no argument whatever that would convince me in favour of such compulsory cards. I fully understand the arguments in favour of voluntary identity cards; such cards are different and all of us carry a large number of what amount to voluntary identity cards. There is a case for bringing together such cards, and we are considering it.

Mr. Jonathan Sayeed (Mid-Bedfordshire): Does the Home Secretary agree that the law-abiding have nothing to fear from the introduction of a national identity card? As he has expressed support for a voluntary identity card, why do the Government not get on with putting one into public use?

Mr. Straw: I was making exactly the point that the law-abiding have nothing to fear from a voluntary card. However, I believe that they would find it rather oppressive if, simply as a result of forgetting their wallet, they were faced with the fact that they had committed a criminal offence. The police were hardly in favour of the idea of such compulsion when the matter was raised by the previous Government. As for the hon. Gentleman's encouragement to me to get on with it, we are indeed considering the matter; we do not need many lectures from a supporter of the previous Government, who published a consultative document in 1995, but did nothing thereafter.

Mr. Denis MacShane: Is my right hon. Friend aware that to focus on compulsion might be the wrong approach? Many people would like to have an identity card issued by the Government that authenticates one's age and identity—first, for the purposes of age identification and, secondly, to facilitate travel. People in the rest of Europe travel on ID cards without having to wait for a passport—something which many of my constituents tell me is a problem at the moment. Given

that 30-odd new Tory Europhobes are now to be going to and from Europe, would it not be helpful, before they go native, to give them an ID card to remind them that they are still British?

Mr. Straw: Yes—and we would make sure that it had the Union flag on it.
Turning to the 99 per cent. of my hon. Friend's question that was serious, I think he is right to say that, in many ways, the debate about whether cards should be compulsory is a diversion. I see few merits in making failure to carry a card a criminal offence; if that is accepted, we can move on to a serious debate on the circumstances in which a general identity card could be introduced.

Mr. A. J. Beith: I welcome the Home Secretary's recognition that there are strong objections to making the rights of citizenship dependent on carrying a particular Government identity document, but does he also recognise the practical difficulties? Is the Government machine capable of issuing large numbers of identity cards, given that there are thousands of people queueing in the streets of Liverpool and tens of thousands who cannot obtain a passport in time to go away on holiday? What would such problems be like if they were all waiting for an identity card?

Mr. Straw: Let me make it clear, as has the Under-Secretary of State for the Home Department, my hon. Friend the Member for North Warwickshire (Mr. O'Brien), that I greatly regret the administrative problems that have arisen in respect of the issue of passports following the introduction of the new information technology contract. We are working hard to clear the backlog: many hundreds of thousands of passports have been issued, and the introduction of a fast track has been almost completely successful in ensuring that people receive their passports, if they put on the application form the date by which they have to travel.

Mr. James Clappison: Is not the Home Secretary being somewhat complacent about the question of passports? Is not the hon. Member for Rotherham (Mr. MacShane) right—uncharacteristically and in only one respect—to say that it would be a matter of concern if the Passport Agency were to be responsible for the administration of identity cards? Will the Home Secretary give a guarantee that people—especially the people of Liverpool—will not be put through the trauma and worry of waiting for their passports to be returned by that agency? Have not the Government managed to isolate British citizens who want to travel—isolate them from Europe and from anywhere else—through their incompetence in the administration of the system?

Mr. Straw: No, I do not accept that. I am not in the least complacent about the problems that have arisen and there was no suggestion of complacency in my answer to the right hon. Member for Berwick-upon-Tweed (Mr. Beith). I deeply regret the fact that the administrative problems have arisen, and we are doing all that we can to overcome them. Sadly, the introduction of large-scale IT contracts in both the public service and the private sector is all too frequently followed by such


administrative problems. The agency is recruiting 300 additional staff to reduce the arrears, and we hope to overcome the problems shortly.

Crimestoppers

Mr. Paul Goggins: What action he is taking to support Crimestoppers. [85568]

The Parliamentary Under-Secretary of State for the Home Department (Mr. George Howarth): We greatly appreciate the work of Crimestoppers, especially the way in which it allows the anonymous reporting of crime. Ministers attend Crimestoppers events to support its work whenever possible—indeed, I attended a national conference in Birmingham in November. We are holding discussions with Crimestoppers about ways in which we might work together and support it in its work.

Mr. Goggins: In thanking my hon. Friend for his answer, may I point out that one in six of all the cases leading to arrest and charging carried out under the auspices of Crimestoppers have occurred in Greater Manchester? Does he agree that the two main reasons for that success are, first, the good quality of media coverage and, secondly, the high level of support from Greater Manchester police, which provides three full-time detectives as its contribution to Crimestoppers? Will he encourage other police forces to follow the example of Greater Manchester police? Will he consider the possibility of Home Office funding, both for joint projects with Crimestoppers, and to cover some of its core costs?

Mr. Howarth: I join my hon. Friend in congratulating the Greater Manchester police on the work that they do in co-operation with Crimestoppers. That kind of partnership between different agencies and the police is important if we are to combat crime successfully. I understand that Crimestoppers has not yet made any specific formal request to the Home Office for direct funding, but obviously any such request will receive serious consideration. I remind my hon. Friend that we are discussing with Crimestoppers how we can support its work, which we take very seriously.

Organised Crime (EU Enlargement)

Caroline Flint: What plans he has to ensure that applicants to become European Union members meet the required standards in combating organised crime. [R][85569]

The Parliamentary Under-Secretary of State for the Home Department (Kate Hoey): The United Kingdom is doing its utmost to ensure that the applicant states meet the required standards laid down by the European Commission in the area of justice and home affairs matters. Measures to combat organised crime form a major part of those requirements. United Kingdom law enforcement agencies are playing a major role in providing training and assistance under the European Union twinning programme and other United Kingdom initiatives to help ensure that standards are met.

Caroline Flint: As the Minister will be aware, organised crime knows no national boundaries. Will she

outline how training and assistance will be applied to ensure that there is proper adherence when countries become members of the European Union?

Kate Hoey: The United Kingdom has been selected to lead four twinning projects on organised crime and related policing matters in Hungary, Slovakia, Romania and Poland and to participate in a fifth in the Czech Republic. That is a recognition of the United Kingdom's law enforcement capabilities and how good our law enforcement is. We will try to encourage EU applicant countries to examine their training and support systems and their accountability and, as my hon. Friend said, to consider the main benefits that will accrue from improving law enforcement agent capabilities through nations joining to fight organised crime effectively as a partnership.

Mr. Desmond Swayne: Will the Minister assure the House that the Government will resist extending corpus juris—which is alien to the concept of habeas corpus—to the justice systems either of EU applicant countries, as a condition of membership, or of existing member countries?

Kate Hoey: Yes, the hon. Gentleman has my full assurance.

Licensing Laws

Mr. Brian Jenkins: What discussions he has had with the parliamentary beer club about its research into licensing laws. [85570]

The Parliamentary Under-Secretary of State for the Home Department (Mr. George Howarth): I met club representatives on 2 July 1998 and 27 January 1999 to discuss how they could contribute most helpfully to the Government's review of licensing laws. The club has been examining licensing systems abroad and is developing its own ideas for reform. I look forward to receiving the club's report, and I am grateful for the advice that it has provided so far about this important subject.

Mr. Jenkins: Does my hon. Friend realise that the extension of hours will benefit the trade in this country and that the change will cause no problems for many well-run organisations? However, is my hon. Friend aware of the term "fun pub"? For many residents who live near such places, they are not fun pubs but neighbours from hell. What extra regulations will my hon. Friend put in place to ensure that those residents' quality of life is not diminished further? How can they be sure that their normal life will continue?

Mr. Howarth: My hon. Friend raises a serious problem that deserves our proper attention. The aim of the current review is to balance residents' legitimate concerns—not only about fun pubs but about any licensed premises near their home where there may be disturbances at closing time or at other times—with other people's right to enjoy themselves at a time that is convenient and fits in with how they want to lead their lives. We want a licensing system that is robust enough to defend residents while allowing people to exercise their market choice as consumers.

Mrs. Jacqui Lait: Is the Minister aware of the beer club's research into the smuggling and bootlegging of beer? Does he agree that the problem undermines the rule of law and is becoming increasingly costly to police forces throughout the country, particularly in big cities? Will he give the House an idea of what the Home Office is doing to combat that crime caused by the Treasury?

Mr. Howarth: The hon. Lady is right to say that the smuggling of beer and other products to evade duty is a serious problem, and we all probably have some constituency experience of that. Young people are often a target group for those smugglers, and we have a serious programme to try to make it harder for anyone to sell alcohol to young people. My Treasury colleagues are aware of the difficulties and of the amount of revenue that is lost, and they are working on ways to combat that serious problem. The hon. Lady is right to draw attention to it, and we have plans to tackle it in the near future.

Domestic Violence

Mr. Ben Chapman: If he will make a statement on help offered by his Department to victims of domestic violence. [85571]

The Parliamentary Under-Secretary of State for the Home Department (Kate Hoey): We have launched an awareness campaign; we have improved funding for the Women's Aid Federation and victim support; we have implemented provisions in the Protection from Harassment Act 1997 and the Family Law Act 1996 and we are speeding up justice for victims and protecting vulnerable witnesses.

Mr. Chapman: Violence against women in the home represents a quarter of all violent crime. Does my hon. Friend agree that this scourge needs to be tackled, that it must be given priority and that there must be partnership between agencies and the Government? Will she join me in welcoming the initiative to be launched on Merseyside next month, "zero tolerance for women and children", which will attempt to tackle the problem on that basis?

Kate Hoey: My hon. Friend is right: 25 per cent. of all violent crime is perpetrated against women and it has to be tackled at the highest levels and with the greatest co-operation between all agencies. Of course we welcome all the many initiatives around the country, and I welcome particularly the zero tolerance campaign to which my hon. Friend refers.

Elderly People (Assaults)

Mr. Bill O'Brien: What recent reports he has received from police forces in England on attacks on elderly people; what advice he gives to the police on protecting the most vulnerable members of society; and if he will make a statement. [85572]

The Minister of State, Home Office (Mr. Paul Boateng): The Government, through the Crime and Disorder Act 1998, have encouraged the police and local authorities to work in partnership with other local organisations to tackle crime against the elderly where

that has been identified as a local problem. There are many examples of successful local initiatives to deal with bogus callers and those who commit other crimes that particularly affect the elderly, including the doorstep code introduced by the West Yorkshire police, which has made a particularly valuable contribution.

Mr. O'Brien: I thank my hon. Friend for that response and also for his Department's effort and its provision of £50 million for the next three years to try to help communities that have high burglary rates. I am concerned about the number of elderly people who feel isolated and socially excluded for want of better street lighting and better lighting around their premises, and more secure doors and windows in their homes to try to prevent people from breaking in and attacking them. It was recently reported that an elderly widow had been murdered in her home, and over the past two years, two of my elderly constituents have been murdered in their homes. My local newspaper regularly reports that elderly people have been attacked, mugged and threatened by people in their community. We need to concentrate more on protecting the most vulnerable people from those bullies.

Mr. Boateng: My hon. Friend rightly identifies crime against the elderly as being essentially a quality-of-life issue for the elderly. There can be nothing more debilitating for an elderly person than the fear that when they go down the road to pick up their daily paper they will return to find that their house has been burgled, or that they will be subjected to harassment while they are going to or from their home. That is why my right hon. Friend the Home Secretary introduced the Crime and Disorder Act and why we are placing particular emphasis on target hardening.
Part of the £50 million that will underpin the Crime and Disorder Act will be spent on providing the nuts-and-bolts practical advice and assistance to which the elderly are entitled. That will give them the proper sense of safety and security in their home.

Mr. James Gray: Does the Minister agree that not only such worthwhile initiatives but sentencing policy should take care of the most vulnerable in our society—the elderly and the very young? Is he aware of a very alarming case in Swindon, which was announced, I think this morning, of the release into my constituency on three years' probation of a paedophile who has been convicted of 17 separate offences against very young children? Does he agree that that sends out the wrong message to paedophiles, and a very alarming one to mothers of young children in my constituency?

Mr. Boateng: It would be wrong of me to comment on an individual case, but I would be only too happy to meet the hon. Gentleman to discuss sentencing policy generally, because this House will wish the clearest message to be sent to those who prey on the vulnerable—be they young or old—that they will be punished, and punished severely, when they offend in such a way.

European Elections

Mr. Martin Linton: What measures he proposes to increase participation in elections following the result of the European elections. [85574]

The Secretary of State for the Home Department (Mr. Jack Straw): The turnout for most countries in Europe fell significantly for these elections, including in some countries—notably Austria, Finland and Germany—by a greater margin than that in this country. Disappointingly, the United Kingdom level was none the less the lowest of any member state, reflecting in part a wider problem with turnouts in the UK. The Under-Secretary of State for the Home Department, my hon. Friend the Member for Knowsley, North and Sefton, East (Mr. Howarth), has been chairing a working party on electoral procedures, on which the main Opposition parties are represented. That will be making a number of recommendations that are intended to improve turnout.

Mr. Linton: Does the Home Secretary accept that Britain is now the apathy capital of Europe, with the lowest turnout in Europe and, indeed, in any European election, ever? Does he also accept that that cannot be blamed on the voting system, since on the very same day, we had the lowest by-election turnout since the war—the lowest peacetime by-election turnout since 1919—and only a month ago, we had the lowest local election turnout for at least a quarter of a century? None of the major parties can draw any comfort from the results, since all voting figures were lower than those for the previous European election. Indeed, the votes for Labour and the Conservatives were the lowest ever in a European election. Even after the counts in Northern Ireland and Scotland, the Tories will have had their lowest vote ever. So, every party should support the measures—

Madam Speaker: Order. Does the hon. Gentleman realise that he is supposed to be putting a question and not making a statement? I should be glad if he would pose his question to the Home Secretary—and immediately.

Mr. Linton: Will my right hon. Friend the Home Secretary make proposals to encourage voter participation through measures including early voting at any time in election week, personal and proxy voting on demand, all-year voter registration, weekend voting, citizenship education in schools and perhaps also lower council tax for those who have voted?

Mr. Straw: My hon. Friend is entirely right—there ought to be consensus on this among all parties—that, irrespective of the voting system used, there is a need for us to ensure rising participation in British elections and British politics. I am pleased to say that the working party chaired by my hon. Friend the Under-Secretary is not only considering, but will be making recommendations on, a more imaginative approach to election systems. We must remember that arrangements for the current electoral system were set in the 19th century and have hardly been altered since then. We must bring them up to date for the 21st century.
Recommendations will include ideas about voting in supermarkets, railway stations and shopping centres, the possibility of weekend voting and the much more

extensive use of postal voting, including electronic voting as well as use of the Post Office. All such proposals require very careful examination and support from all political parties if we are to raise participation in British politics.

Dr. Julian Lewis: In the spirit of cross-party consensus and co-operation engendered by the introduction of the dreadful proportional representation system, may I give the Home Secretary a tip for free? If he wants to increase participation in future European elections, let the Labour party take a leaf out of the Conservative book and bring its position into line with the views of 60 per cent. of the people, who do not want this country to enter the single European currency.

Mr. Straw: As ever, I am grateful to the hon. Gentleman for his gratuitous advice—[Interruption.] I quite understand Conservative Members' excitement. In Labour's 18 years of opposition we had such moments, when we thought that victory had finally arrived, and all too often we discovered, the next day, that life returned to normal and we faced another 17, 16, 15 or 14 years of Conservative rule—so I sympathise with Conservative Members. I congratulate them on their victory in these European elections; they should savour the day. Meanwhile, we will return to the business of governing the country.

Mr. Dennis Skinner: But would it not be wise of the Home Secretary to learn the lessons of what happened on Thursday? There were several. One is that it is pretty clear that proportional representation is not a very good idea in Britain, even if it is in some other parts of Europe. I know that my right hon. Friend is not a paid-up member of those who are for proportional representation. He should also remember that the British people do not go a bundle on the Common Market. The third—and perhaps the most important—lesson is that it is high time that the Labour Government paid a little more attention to their hard-core working-class old Labour vote and perhaps not so much to those who live up long winding drives with pampas grass 12 ft high.

Mr. Straw: I pay considerable attention to the first category of Labour voters that my hon. Friend mentions. There are not many gravel drives in Blackburn—although there are some—and there is certainly little in the way of pampas grass. On systems of proportional representation, I believe that the House must take note of the fact that, following decisions in which the previous Government were complicit, this country has been required to introduce a common system for elections since 1979 and, following the treaty of Amsterdam, has been required to introduce—[HON. MEMBERS: "That's yours."] Hang on; I know that it was our responsibility, but I do not recall any objections being raised by Conservative Members—[HON. MEMBERS: "What?"]—to this bit. Common principles have been introduced for elections, but scope remains for adjustment of the systems used. As I told the House during the passage of the European Parliamentary Elections Bill last year, we shall establish a review of electoral arrangements—quite apart from the working party chaired by my hon. Friend the Under-Secretary of State, which will obviously examine those arrangements.

Mr. Dafydd Wigley: Is the Home Secretary aware that among the highest turnouts last


Thursday were those in the elections in Wales, but that they were also far from satisfactory? Does he recognise that turnout was higher in those constituencies where parties were proactively involved in campaigning? In his review, will he consider having an open list, not a closed list, because the identification with an individual certainly leads to a higher turnout? Finally, will he bear in mind the need to consider the requirements of disabled people in particular, so that they can turn out to vote more easily, not only in European elections but in all elections? I believe that the Home Office has a meeting on that subject this afternoon.

Mr. Straw: The right hon. Gentleman is quite right to draw attention to the relatively high turnout in Wales, which, at 28 per cent., was the highest of any part of Great Britain—we do not yet have the Northern Ireland results. That was impressive. The nature of the list system used is a matter for the House. We had many debates about that before the passage of the European Parliamentary Elections Act 1999, and I rather expect that those debates will continue.
The right hon. Gentleman is right to raise the issue of making it easier for disabled people to vote. That is one of the reasons why I believe that there is a strong case, although it may require legislation, for greatly extending the facility of postal voting, including electronic telephone postal voting.

Mrs. Gwyneth Dunwoody: The Home Secretary will remember that he promised us a review. We think that it is an excellent idea, and we hope that he gets on with it and throws out most of the rubbish that we are stuck with at present. Will he bear in mind the fact that there is no doubt that the British voter positively dislikes closed lists? Voters want to know which representative they are voting for. Some of us who voted Labour were strongly, strongly tempted to strike out one or two names on the list, and had great difficulty resisting that temptation.

Mr. Straw: Even had my hon. Friend done so, it would not have spoilt her paper. She should bear that in mind.

Mrs. Dunwoody: Now he tells me.

Mr. Straw: Without reworking old arguments, which will clearly become new arguments, it is worth pointing out that even under the closed list, people knew who they were voting for, and that each of us, including my hon. Friend, was elected under a closed list, if by that she means a system whereby the party puts forward the candidate for election, not the individual voter choosing the candidate from a particular party.

Sir Norman Fowler: There will be a great deal of sympathy with the comments of the hon. Member for Bolsover (Mr. Skinner) about the Government's policy. May I make it clear to him that there is an open door to new recruits, from wherever they may come.
On the voting system, will the Home Secretary confirm that had the elections been on the first-past-the-post system, Labour would have lost even more seats last night

than it did, which is why so many Labour Back Benchers are so twitchy today, and that the Liberal Democrats would have been entirely wiped out?

Mr. Straw: That all depends on one's assumption. Others on the Conservative Benches, and probably even the right hon. Gentleman himself, were arguing that first past the post would have led to an increase in turnout, in which case Labour would have done better under the closed list, rather than worse. Whatever else one says about the closed-list system, never in the history of British politics has there been an act of greater generosity by a governing party to both opposition parties than our introduction of the closed list.

Sir Norman Fowler: The right hon. Gentleman has obviously misunderstood what happened in the elections. If they had been conducted under the first-past-the-post system, the Conservatives would have won more, not fewer, seats, and his party would have lost more. Does he not understand that?
The answers to my questions, which the right hon. Gentleman was unable to give, were yes and yes. Will he concede that we had debate after debate on the Floor of the House in which, although we opposed the closed-list system, the Liberal Democrats did not? I believe that they will concede that. [Interruption.] Do they have loss of memory, as well as loss of seats? Is it not clear that the closed-list system has been rejected by the public, just as certainly as they have rejected the Government's policy on Europe?

Mr. Straw: I am confused by the right hon. Gentleman's question. If he is claiming victory for the Conservative party's results
under the closed-list system, it is difficult for him also to argue that the Conservative party has somehow been rejected, having been elected under that system. He is right to say that the Conservatives opposed the closed-list system. So far as I recall, so too did the Liberal Democrats. That is a matter of record, as the right hon. Member for Berwick-upon-Tweed (Mr. Beith) will remember. There were many arguments in favour of the closed-list system, and he will recall that I advanced them to the complete satisfaction of my right hon. and hon. Friends.

Police Funding

Mr. Gareth Thomas: What research he has commissioned on the impact of increases in funding of police forces on their performance. [85575]

The Secretary of State for the Home Department (Mr. Jack Straw): The Audit Commission publishes an annual report on police performance. Her Majesty's inspectorate of constabulary visits each force every year and conducts full inspections of each force every three years, along with regular thematic inspections across forces. The last Audit Commission annual report, published in January this year, found that there was no direct link between increased spending and improved performance in police force areas.

Mr. Thomas: I thank my right hon. Friend for that answer. If there is no such direct link, presumably efficiency has a large part to play in terms of performance.


That being so, what steps does my right hon. Friend suggest could be taken to improve the operational efficiency of the police with a view to making them more visible, particularly in market towns?

Mr. Straw: We have set a challenging but realistic efficiency agenda for the police service. We are asking it to find 2 per cent. efficiency savings, which it then reinvests in its own front-line operational performance. There are many ways in which the police service can improve operational efficiency, not least—but by no means exclusively—by tackling too-high levels of sickness and early retirement through alleged ill health.

Mr. Patrick McLoughlin: Does the Home Secretary accept that while examining performance, it is important also to consider whether the police can lock up criminals? With that in mind, will the right hon. Gentleman examine closely a case that was heard last week in Derbyshire when the police, refusing to name an informant, had to drop the case in the Crown court, thus allowing someone charged with a serious crime to get away, to protect the informant? Will he look at this matter, which is obviously very serious?

Mr. Straw: I shall look at the case and I shall be happy to see the hon. Gentleman about it. The disclosure of informants' names is an important and sensitive issue. As the House knows, following proposals from the previous Government, there was broad agreement across the Chamber about changing the rules on disclosure in the Criminal Procedure and Investigations Act 1996. I accept that those rules may need to be strengthened further.

Social Exclusion

Mrs. Joan Humble: What representations he has received on the role of the voluntary sector in tackling social exclusion. [85576]

The Minister of State, Home Office (Mr. Paul Boateng): The voluntary and community sector has a key role to play in tackling social exclusion. The Government recognise that many voluntary and community organisations have particular skills and knowledge across a range of subject areas and service provision. That is why the Government have entered into a new spirit of partnership with the sector, and why the policy action teams established to take forward the work on social exclusion use and rely heavily on the contributions of representatives from a range of voluntary organisations.

Mrs. Humble: I thank my hon. Friend for that reply. May I encourage him to invite as wide a variety of voluntary organisations as possible to participate in the debate? For example, only a couple of weeks ago I attended a meeting of the Blackpool Women's Aid organisation. It is keen that the work that it undertakes to combat domestic violence is seen as part of the strategy to combat social exclusion.

Mr. Boateng: Domestic violence is a real threat in terms of law and order—we should never forget that it is a crime—and because it has an appalling impact on the immediate victims, namely women. It is usually women

who are the subject of domestic violence, along with their children. By all the indices of deprivation—for example, failure at school and mental health problems—domestic violence plays its part, and is seen to do so. Women's Aid and other voluntary organisations have, and will continue to have, a key role in the development of our strategy to combat domestic violence.

Mr. Ian Bruce: Has the hon. Gentleman examined what has happened with regard to the minimum wage legislation as it applies to voluntary organisations? Many voluntary organisations have people who are paid a small amount to help them with their general expenses. As a result, people have been able to volunteer to help at a women's refuge, a playgroup or whatever. Are these organisations being affected by the fact that people are not able to carry on helping them because they have to be paid the full minimum wage, despite the fact that they are happy to volunteer to work for a couple of pounds an hour?

Mr. Boateng: On the contrary, the National Council for Voluntary Organisations supported the introduction of the minimum wage. There is no way that effective voluntaryism can ever be based on poverty wages.

Neighbourhood Renewal

Ms Christine Russell: If he will make a statement on his Department's role in neighbourhood renewal. [85577]

The Minister of State, Home Office (Mr. Paul Boateng): Officials in my Department are working with colleagues across Whitehall on a range of initiatives to promote neighbourhood renewal. Those include the Government's response to the social exclusion unit's report on neighbourhood renewal, the single regeneration budget and the new deal for communities, all of which are playing an important part in ensuring that neighbourhood renewal and combating social exclusion go hand in hand.

Ms Russell: I thank my hon. Friend for that answer. Will he join me in congratulating Cheshire constabulary, Cheshire county council and Chester city council on working tremendously hard to put together a community safety partnership, which I had the honour of launching a couple of weeks ago? Will he comment on community safety partnerships in general, which, like all the other initiatives he mentioned, will play a part if we are to repair the social fabric of all our communities? We must recognise the vital role that community partnerships can play, because we need not only to repair the social fabric and the bricks and mortar of our communities after 16 years of neglect, but to tackle crime and the fear of crime.

Mr. Boateng: I am obliged to my hon. Friend. I have had the opportunity to visit Chester, and I heard a presentation and saw for myself the excellent work that is being done by the voluntary sector, particularly in relation to drugs and reducing drug use among young people. The local business sector, the police and the local authority are getting together to make a clear and real contribution


to reducing drug abuse in Chester. That is good news for the young people concerned and good news in terms of the effect of drug abuse on crime generally.

Mr. John Bercow: After reflecting on measures to assist the renewal of neighbourhoods, does the Minister agree that, far from being a harmless if self-indulgent activity, the spread of graffiti at bus stops, on the walls of public buildings and in other places is corrosive of the forward-looking spirit and the sense of self-respect that are essential to the regeneration of neighbourhoods? Will he therefore confirm that the Government take a dim view of such behaviour and will introduce tougher measures to root out that unattractive phenomenon in our society?

Mr. Boateng: I agree wholeheartedly with the hon. Gentleman. Such graffiti often represent a form of visual violence that is totally unacceptable. Care and concern for the built environment is central to neighbourhood renewal, and I am glad that so many local authorities across the country are recognising that by establishing 24-hour schemes to deal with graffiti. We need more people to take that approach, and we are determined to encourage and support it through our crime and disorder partnerships.

Asylum Applicants (Support)

Mr. Mike Gapes: If he will make a statement on his plans to change the system of support for asylum applicants. [85578]

The Secretary of State for the Home Department (Mr. Jack Straw): As I announced to the House last Wednesday, I have decided to increase the cash amount paid to asylum seekers and to clarify the Secretary of State's responsibilities for the children of asylum seekers.

Mr. Gapes: I welcome that answer, but does my right hon. Friend agree that the best way to help those many thousands of people who flee oppression and discrimination, some of whom come to this country, is to ensure that quick decisions are made about their status so that they do not have to wait months—or years, in many cases—before a decision is made?
Will my right hon. Friend give the House an assurance that renewed, strenuous efforts will be made to sort out the chaotic inheritance that the previous Government left at Croydon, and the incompetent computer system which has caused so many problems for so many of my constituents and others? Will he also do something to deal with the crooks, spivs and racketeers purporting to be immigration advisers—some of whom are solicitors—to get them out of the system? That will make sure that our constituents do not suffer from incompetent, misleading advice and that the legal aid system is not abused by such people.

Mr. Straw: I agree with virtually everything that my hon. Friend said. We are profoundly committed to introducing much faster decision making in the asylum system. We are sticking to the two-months and four-months targets for all asylum applicants from April 2001, but I have already made it clear, in the answer that I gave the House last Wednesday, that we intend to process family cases within two months after the introduction of the asylum support directorate arrangements from April next year.
My hon. Friend is right to refer to the crooks, spivs and racketeers. I am afraid to say that they include too many members of the legal profession who have got rich by manufacturing asylum claims. Part of the purpose of the Immigration and Asylum Bill, which has its Report stage in this House tomorrow and Wednesday, is to crack down on exactly such activity.

Miss Anne McIntosh: We have received the first Kosovan refugees in the Vale of York at New Earswick. The local authority responsible, the City of York, has raised a number of questions concerning the outstanding financial arrangements to be decided by the Home Secretary and his Department. Can the Home Secretary assure us that an early answer will be given?

Mr. Straw: Yes, I can. If the hon. Lady has any further problems on behalf of the local authority, I shall be happy to take them up. I have made it clear that central Government will pay the additional costs incurred by local authorities and the voluntary sector. I understand that my right hon. Friend the Minister for Local Government and Housing will shortly write to all local authorities and voluntary organisations, setting out the detailed arrangements.

Mr. Neil Gerrard: Although I very much welcome what my right hon. Friend has said about speeding up the system, does he agree that the best way to deal with people who make fraudulent claims is to make a quick decision and to enforce it? If most decisions on families are to be made within eight weeks of their making an application, is it worth setting up what amounts to an alternative Benefits Agency in the Home Office to administer the system, to place them up and down the country, and to issue and redeem the vouchers? Would not it be simpler to restore the right to benefits to families, to make decisions quickly and to enforce them on people who make fraudulent claims?

Mr. Straw: I regret to say that I do not agree with my hon. Friend's assumptions. There is no doubt that the availability of cash benefits in the social security system is a major pull factor that encourages fraudulent claims at port. It is one of the factors that encourages many people whose claims are wholly without foundation to come in clandestinely, particularly to Dover and other south-east ports, from eastern Europe and other countries where they are not under any threat of persecution. They come in principally to claim cash benefits. That is unacceptable, and has placed a disproportionate burden on Kent authorities and on 10 London boroughs, which, between them, account for more than 50 per cent. of asylum seekers being supported by local authorities. I can tell my hon. Friend, who represents one of those London boroughs, that the only practical way to remove the burden from those boroughs and the Kent authorities is to have a national dispersal and asylum support system such as we propose.

Kosovan Refugees

Mr. Nigel Waterson: How many Kosovan refugees are currently being accommodated in (i) the United Kingdom, (ii) East Sussex and (iii) Eastbourne. [85579]

The Parliamentary Under-Secretary of State for the Home Department (Mr. Mike O'Brien): So far, 3,773 Kosovan evacuees have been airlifted to Britain under the United Nations High Commissioner for Refugees programme. Most of them have been housed in the midlands, the north of England and Scotland. However, 12,360 nationals of the former Yugoslavia have applied for asylum in the United Kingdom since 1996. We cannot identify the precise number living in East Sussex or Eastbourne without examining individual cases.

Mr. Waterson: Despite the fact that the Minister cannot give me the current figures, can he project how many of these refugees will eventually be housed in East Sussex and in my constituency? Will he give the House an assurance that there will be the closest and most detailed consultation between central Government and local government to ensure that the arrangements are proper, efficiently handled and put no undue extra burden on overstretched services in particular areas?

Mr. O'Brien: The hon. Gentleman makes a reasonable request. We shall endeavour to ensure that there is full consultation with the local authorities and that they are given as much information as possible about the numbers that they should expect in their area. We shall try to ensure that the arrangements for meeting any additional costs are arrived at after full and proper consultation.

Fiona Mactaggart: The Kosovan refugees have largely been accepted into hostels and settlement centres. Will my hon. Friend the Minister consider whether that approach might be appropriate for other groups of refugees if it is successful? Will he assure the House that the research unit in the Home Office will look carefully at the consequences of new decisions on support systems so that we learn the lessons of new arrangements for supporting refugees?

Mr. O'Brien: My hon. Friend asks two reasonable questions. I hope that I can give a positive response on both. The voluntary sector's use of reception centres for the Kosovans has been successful. We are looking closely at the lessons to be learned from that. We want to be sure that we get it right when we introduce new systems. We can learn a lot from our experience with the Kosovans. We want to ensure that research into support mechanisms is done effectively and that we learn lessons from it.

Closed Circuit Television

Mr. Tony McNulty: What research his Department has commissioned about the effects of CCTV on crime levels. [85580]

The Parliamentary Under-Secretary of State for the Home Department (Mr. Mike O'Brien): Research by the Home Office police research group has shown that closed circuit television reduces crime and, importantly, the fear of crime, particularly when it is deployed as part of a wider crime reduction strategy. We shall assess the effectiveness of schemes that received funding under the CCTV challenge competition as the information becomes available.

Mr. McNulty: I thank my hon. Friend for that answer and congratulate the councils of all parties across the

country which have successfully implemented CCTV. I should like assurances on two points. First, should not all subsequent bids be rooted in an understanding of local crime and disorder audits and strategies? Secondly, some independent research has been carried out on dispersal, but far more is needed so that we can be assured that the intuitive view that CCTV simply disperses crime elsewhere is not right.

Mr. O'Brien: I can assure my hon. Friend on both points. We want to ensure that any application for CCTV funding is rooted firmly in the local crime and disorder audits. We also want to ensure that displacement of crime is studied properly. A study commissioned by the Scottish Office of the CCTV system in Airdrie found that there was no evidence of displacement and that there was a genuine reduction in crime as a result of CCTV. We want to build on that, but my hon. Friend is right to say that we need to ensure that research is done on an even broader basis.

Mr. Edward Garnier: During the assessment that the Minister mentioned, will he make a comparison between the situation in Market Harborough and that in the borough of Oadby and Wigston, both of which are in my constituency? CCTV was introduced in Market Harborough under the Conservative Government, but the Liberal Democrat borough council in Oadby and Wigston has refused to apply to the Home Office for funding under the previous Government and under this Government. Will he make a point of comparing levels of crime in the two areas so that the benefits can be made clear to the feckless Liberal Democrat council in my constituency?

Mr. O'Brien: That might be an interesting comparison, but the hon. and learned Gentleman should know that when we came to office, there was only £1 million left in the budget for CCTV. We have introduced a £170 million CCTV initiative that involves £150 million for England and Wales, £13 million for Scotland, £4 million for Northern Ireland and £3 million for Wales. That money is tied into a £250 million crime reduction package. We are investing in reducing crime, whereas the previous Government merely talked about it.

WPC Fletcher

Mr. Tam Dalyell: If he will make a statement on the progress made in the inquiry relating to the murder of WPC Fletcher. [85581]

The Secretary of State for the Home Department (Mr. Jack Straw): The Metropolitan police have recently completed the report of their review of the evidence surrounding WPC Fletcher's murder and of the allegations made in the "Dispatches" programmes, and I understand that no evidence or intelligence was found to corroborate those allegations. Instead, the review has supported the findings of the original investigation that WPC Fletcher was killed by a bullet fired from the first floor of the Libyan People's Bureau.

Mr. Dalyell: I thank my right hon. Friend the Home Secretary for his sustained personal interest in the matter and for his letter of 3 June. Will the criminal investigation in conjunction with the Libyan authorities take a long time? What is the hoped-for time scale?

Mr. Straw: First, I am grateful to my hon. Friend for his remarks, but I wish to thank him in return for his great

forbearance because the investigation by the Metropolitan police took much longer than anybody anticipated. As I said to him in my letter, that is at least testament to the thoroughness with which the review was conducted. I cannot give my hon. Friend a precise answer to his second question, but I am happy to write to him and, as I said in my letter of 3 June, to meet him to brief him in more detail about the nature of the review.

Kosovo

The Secretary of State for Foreign and Commonwealth Affairs (Mr. Robin Cook): With permission, Madam Speaker, I will make a statement on recent developments on Kosovo.
Today is the fifth day since the entry into force of the military agreement. I can report to the House that Serb forces are leaving Kosovo broadly in line with the phased withdrawal set out in that agreement. Meanwhile, NATO forces have entered much of southern and central Kosovo and are ahead of the planned timetable for their deployment. A quarter of all troops so far deployed are from the United Kingdom—the largest single national contingent. The whole House will wish to congratulate our troops on the professionalism with which they have deployed so quickly and efficiently.
Members of the House will have seen pictures of the spontaneous welcome the troops have received from Kosovo Albanians wherever they have gone. The warmth with which those Albanians have expressed their joy at our arrival speaks volumes for the brutality and the terror from which our campaign has liberated them. For the past two months they have seen their neighbours massacred, their young relatives raped and their homes burnt. Now, they can see a future in which none of those crimes can return to haunt Kosovo.
The presence of the Russian troops around the airport has not interfered with the deployment of NATO forces. Our forces are entering as planned from Macedonia. It is important to keep a sense of perspective on the numbers involved; there are only a couple of hundred Russian troops in Kosovo, compared with 14,000 NATO troops today.
General Jackson this morning had a business like meeting with General Zavarzin, the commander of the Russian troops at Pristina airport. He has just reported that he hopes that agreement can be reached on assimilating the Russian troops into KFOR. Nevertheless, it was plainly unsatisfactory that Russian troops should have entered without co-ordination. Yesterday, I spoke at length to Igor Ivanov, the Russian Foreign Minister, and we agreed that there should be no more surprise moves. He gave an undertaking that Russia would not deploy any further troops without prior agreement. Earlier undertakings about Russian deployments have not all been respected. It is crucial that this undertaking should be fully respected.
Negotiations, led by the United States, continue over how Russia's contribution to KFOR can be integrated into the overall operation. Those have been protracted negotiations. On the Russian side, its military have sought a sector of their own. On our side, we have insisted that any outcome must meet the terms of the peace plan for a single operation with a unified chain of command. There is no provision anywhere in the peace plan for partition of Kosovo.
Several non-NATO countries will contribute to forces in Kosovo. I have always made it clear that we would welcome Russia also working with us as partners in the peacekeeping force, but it must be as part of a single, integrated operation, not as an independent force. That reflects our commitment to liberating the whole, not part of Kosovo.
We now face a major challenge in helping Kosovo to recover from the atrocities of the past year. There are four immediate priorities. First, we must ensure that there is security and safety for all the people of Kosovo, whether Albanian, Serb or from any other ethnic group. KFOR will be alert and robust in ensuring that all Serb forces withdraw from Kosovo within the agreed timetable, which should be completed over the next week. KFOR will also be responsible for the demilitarisation of the Kosovo Liberation Army. I spoke last night to Hashem Thaqi, the leader of the KLA, and stressed that we expect restraint from the KLA as the Serb forces withdraw, and co-operation in our efforts to end all violence in Kosovo.
Secondly, we must provide urgent relief to the hundreds of thousands of displaced persons who have spent the past two months hiding from Serb forces on the hillsides and in the forests of Kosovo. A convoy with much British support delivered humanitarian supplies to Pristina yesterday on behalf of the United Nations High Commissioner for Refugees and is reloading today in Macedonia.
Thirdly, we must manage the return of the masses of refugees who were deported as part of Milosevic's failed plan for the ethnic cleansing of Kosovo. We should not be too glib about refugees returning to their homes. Many of those homes have been blown up or burnt down by Serb aggression. We face a major task in helping the bulk of the refugees to rebuild their homes before the Balkan winter sets in. My right hon. Friend the Secretary of State for International Development has today announced a further £50 million for humanitarian relief, on top of the £40 million already provided.
Fourthly, we must record the evidence of the war crimes that have been committed in Kosovo to enforce its ethnic cleansing. There has already been the horrific discovery of a mass grave containing a large number of villagers massacred at Kacanik. We have already started the deployment of a British police team to Macedonia, in order that the International War Crimes Tribunal can draw on its forensic skill and experience in exhuming victims of atrocities and identifying the cause of death. Although we have brought peace to Kosovo, its people will not live at peace with themselves unless we bring to justice those responsible for such atrocities.
For the immediate future, responsibility for the government of Kosovo will be in the hands of an international civil administration, which will be led by the United Nations but will draw on the contributions of the European Union, the Organisation for Security and Co-operation in Europe and the UNHCR. It will be charged with rebuilding the physical infrastructure of Kosovo, regenerating its economy and supervising free elections to new political institutions. Over a period it will transfer its powers to the local people, in line with our goal of democratic self-government for Kosovo.
From the start of the conflict, the Government have stressed that we want it to be a turning point for the whole region. All Serbia's many neighbours have shown total solidarity with the NATO campaign. We must not now forget the courage and commitment that those Governments showed in aligning themselves with us.
On Thursday I attended the launch of the stability pact, a forum bringing together the countries of the region with the European Union, the United States, Russia and other key international players. I pledged that, for our part,


Britain would be their partner in helping to accelerate their integration into the modern Europe. To do that we must open up the wealthy markets of the European Union so that those countries can share in our prosperity through increased trade. We must invest in developing their democratic institutions, civic society and open media in order that they can share in our standards of freedom.
We hope that one day the people of Serbia will also be able to share in the benefits from the stability pact, but first it will be necessary for the Government in Belgrade to renounce the policies of Milosevic, which have brought so much violence to their neighbours and so much poverty to themselves. We cannot embrace Serbia in the modern Europe until Serbia embraces our values of belief in the equality of all citizens, irrespective of ethnic identity, and respect for the rights of minorities.
There would have been no turning point for the countries of the region if the international community had not demonstrated that we would not tolerate the brutality and the ethnic cleansing that Milosevic visited on Kosovo. The revulsion around the world at the expulsion of the Albanians from Kosovo is confirmed in the text of the Security Council resolution, which was drafted by the G8 Foreign Ministers over 12 hours of negotiation last week.
The resolution condemns the violence against the people of Kosovo and demands full co-operation with the International War Crimes Tribunal. It meets all our key objectives: the withdrawal of all Serb forces, the deployment of an international military force with a unified command and the return, without hindrance, of all refugees.
There is much hard work still to be done before we have created a Kosovo that will give its people the opportunity to earn their living in peace. The time to celebrate will be when we have settled all refugees in their homes.
However, all those in the House who supported NATO's campaign can be satisfied with an outcome that has vindicated the strategy of the alliance and its resolve to defeat the forces of ethnic cleansing. We have compelled an end to the atrocities in Kosovo and secured for its people a future free from fear. We have shown that the era of forced mass deportation of a whole people belongs to Europe's past, and that we will not tolerate it coming back again.
We promised the refugees that we would take them back to Kosovo under our protection. We now have the opportunity to fulfil that promise, and we will not slacken in our resolve or our determination until we have helped them all to go home.

Mr. Michael Howard: I thank the Foreign Secretary for his statement. The whole country has been encouraged by the progress made over the past few days. NATO's resolve to see the action through has yielded substantial results. I congratulate the Government and our armed forces on what has been achieved.
As I am sure that the Foreign Secretary will acknowledge, recent developments also demonstrate the extent of the problems still to be overcome and the difficult decisions that must be taken. I join the Foreign

Secretary in paying specific tribute to the crucial role played by General Jackson and to the exemplary performance of the forces that he leads.
Does the Foreign Secretary agree that the ultimate test of success is whether all the refugees feel able to return home across Kosovo? The issue of the composition and deployment of the peacekeeping forces continues to be crucial in this respect. There is obvious concern about the deployment of Russian forces at Pristina airport.
Will the Foreign Secretary confirm that NATO originally planned for British paratroopers to enter Kosovo on Friday morning? Does not article II, paragraph 2a, of the military-technical agreement signed by General Jackson specify that, one day after its entry into force, Yugoslav forces would have vacated zone three and that the international security force would deploy "rapidly" to avoid a "security gap"?
Why were those plans cancelled? Why was a technical and logistical briefing arranged for reporters earlier on Thursday, at which NATO officers would outline the deployment of forces, also cancelled? When did NATO first learn that Russian troops were entering Kosovo?
Is the Foreign Secretary aware that Brcko Radio reported at 10.30 am on Friday that Russian troops had departed from their barracks in Lopare and Zivinice and had crossed the border into Serbia at Pavlovica Cuprija, and that those reports were confirmed by SFOR? Is not it also the case that if, even at that point, British troops had been allowed to move to Pristina, they would have arrived before the Russians? Is the Foreign Secretary aware that a further 150 Russian troops were reported yesterday morning to be waiting at Bijeljina ready to move into Serbia to reinforce Russian troops at the airport?
On the question of the future control of the airport, when does the Foreign Secretary expect that to be resolved? More fundamentally even than that, will he comment on media reports over the weekend that, following the stand-off at the airport, the American envoy Strobe Talbott offered to allow Russia a "zone of responsibility" in Kosovo? Is not that wholly inconsistent with what the Secretary of State for Defence has said in ruling out any suggestion of such a zone in Kosovo, which he described as tantamount to partition of the province?
Will the Foreign Secretary say whether the position in Bosnia, where the Russians are spread across the US-led multinational division (north), is seen as a model for Kosovo? Does he agree that these events have demonstrated once again that any agreements have to be absolutely watertight?
The Foreign Secretary mentioned this morning that the Russian Government provided a commitment over the telephone yesterday that their troops would be integrated into the overall peacekeeping force. When will the terms of that arrangement be finalised? Can he reassure the House that the extent of the buffer zone across the border in Kosovo will be adequate, and will he comment on reports that concessions were made on that issue and on the timetable for the withdrawal of Serbian forces?
There are reports today of further evidence being uncovered—at Kacanik, for example—of horrific war crimes. What arrangements are being made for investigators of war crimes to be given unhindered access to the evidence that they will need?
Last, but by no means least, I welcome today's announcement by the Secretary of State for International Development of further aid for humanitarian relief. Is the


Foreign Secretary satisfied that arrangements are in place to ensure that humanitarian and reconstruction efforts are co-ordinated sufficiently?
Recent events have provided cause for hope in the future in Kosovo. We must ensure that our efforts to secure a lasting settlement that will provide security for all Kosovo's population are not diminished.

Mr. Cook: The Defence Secretary has advised me that there were no plans of the kind described by the right hon. and learned Gentleman for British paratroops. The entry into force agreement prescribes that VJ units will leave from zone three on the first day. Zone three is in the north of Kosovo, adjacent to the Serb border. It was specified for the first day so that the VJ units could show good will and earnest intent by withdrawing into Serbia from the area nearest to it. It was not possible for KFOR forces to occupy the north of Kosovo until forces began to withdraw from the south. There was no way in which to occupy the north without first travelling up from Macedonia.
There has been no security gap. The time of entry into Kosovo by the KFOR forces was determined by the commander, General Jackson, and by no other consideration. It would not have been possible for General Jackson to have reached Pristina airport in advance of the Russian troops for the simple reason that it remained ringed by a large part of the VJ army between the Macedonian border and the airport.
The right hon. and learned Gentleman asked about the negotiations on the military-technical agreement and the buffer zone, and about the time lines. The military had full control on those matters and reached agreements that reflected its practical understanding. I do not regard any extensions of time lines as concessions. They were necessary to provide a realistic time scale for the withdrawal of all Serb forces.
We must recognise that we have substantially reduced the infrastructure during our military campaign. It will therefore take the Serbs a little longer to get out of Kosovo, but get out they will. All of them will have to withdraw. The great advantage of the military-technical agreement is that it provides a day-to-day benchmark by which to measure progress.
I am pleased to confirm that we hope soon to have a scene of crime team in Kosovo. Other nations are considering providing similar assistance to the International War Crimes Tribunal. The team will carry out full investigations of any mass grave or other evidence of atrocity that we uncover, and I fear that we will find much more as we fan out across Kosovo. It was because of British intervention that the Security Council resolution contained a strong demand that all—including the Government in Belgrade—should co-operate with the tribunal.
Finally, I was asked about the arrangements for reconstruction and humanitarian aid. My right hon. Friend the Secretary of State for International Development has collaborated closely with international agencies on those matters. At the Cologne meeting on the stability pact I took the opportunity to speak to Mrs. Ogata, of the UNHCR. We are working hard to try to make all the relevant organisations pull together for a major task. No one should underestimate the challenge or the difficulty of carrying it through.
I thank the right hon. and learned Gentleman for the generosity with which he congratulated the Government and the British forces on what they have achieved during the past few days and in the preceding 10 weeks. There is a long way to go. We must wake every morning alert for the latest trick played by Milosevic. On most days, we will not be disappointed. We have shown in the past 10 weeks that we are more resolved and more determined successfully to see through the campaign. We must now show that we have more resolve and determination than he does to ensure that we win the peace.

Mr. Menzies Campbell: May I also pay tribute to both the Government and the armed forces for the success of the operation—a success that we see every time we turn on our television sets? Behind the understandably careful language of the Secretary of State would we not be realistic to recognise that the unilateral action of the Russians is a potential source of political embarrassment for NATO? If it were repeated, it could cause disruption and increase tension. Indeed, it might even prejudice the effective administration of Kosovo. Do not those difficulties arise directly out of the ambiguity of the United Nations resolution and the annexes to it? If the right hon. Gentleman has read paragraph 7 of the resolution and paragraph 4 of annexe 2, he will know that they are capable of interpretation that does not provide that NATO should have the responsibility for command and control. How is that ambiguity to be resolved satisfactorily? What intelligence assessment, if any, was made of the likelihood of unilateral action by Russia? If none was made, why not?
Finally, the reports of the massacre that are most recently available to us suggest that on this occasion doctors and nurses may have been systematically murdered. Does that not tell us all that we need to know about those with whom we have been dealing in Kosovo—that they should think it right to take the lives of those whose duty it is to preserve life?

Mr. Cook: I echo the right hon. and learned Gentleman's final remarks. It is important to recognise that Kosovo remains a place of some danger. Our forces will show their full professionalism and alertness in ensuring that they maintain their own self-defence while securing security for the people of Kosovo. I invite the right hon. and learned Gentleman to keep the Russian forces in perspective. They are in one part of Kosovo where there are no Albanians and there is no need to return refugees. At the moment, the Russians cannot leave that part and move elsewhere without an agreement with ourselves. We should not get over-exercised by that being a major impediment to the deployment of KFOR and the work that it is carrying out throughout Kosovo. I agree, however, that the unilateralism with which the Russian troops were deployed is disturbing. That must not be repeated if we are to achieve the confidence, trust and sensible agreement that we need for the management of one co-ordinated, whole and integrated operation. A model is available—the right hon. and learned Member for Folkestone and Hythe (Mr. Howard) referred to it—and that is the Bosnian one. For some years, NATO and Russia have worked side by side in partnership in Bosnia with integration at all levels of command. I was pleased that, yesterday, Igor Ivanov volunteered a reference to the Bosnian model as a way forward in the immediate future. I hope that it will help us to proceed with the assimilation


of the Russian troops with NATO into KFOR. We want Russia to be there. Frankly, we want a bigger Russian contribution to securing peace in Kosovo, but it is to be integrated in overall operations.

Mr. Donald Anderson: The Russian swoop on the airfield may not be a major impediment, but it is a possible precedent for problems. Of course, it was right to engage Russia politically and militarily in the solution—it should have been done earlier—but the suggestion that the swoop on the airfield was a misunderstanding strains credulity. Therefore, what lessons have the Government learned in terms of ensuring that there is now a watertight agreement and clear lines of communication to ensure that such misunderstandings, if they arise in future, will speedily be ended?

Mr. Cook: My hon. Friend describes the Russian presence as an impediment, but I repeat to the House that the Russians have provided no practical impediment to the work of KFOR. As I pointed out in my statement, that work is already going on and it is ahead of schedule, not behind schedule.
However, my hon. Friend touches on an extremely valid point: not all the explanations given by Moscow for the deployment of those Russian troops are mutually consistent. We need to achieve clarity in our relations with Russia and in the unified chain of command in order to ensure that there is no repetition of unilateral action. At present, two sets of talks are going on: the talks between General Jackson and his opposite number on the ground about the troops at the airport; and the talks between the United States and Russia about the wider question of the integration into KFOR of the larger Russian contribution that is coming.
Our understanding is that the Russian Government want to find a satisfactory and practical solution to the matter. We should not lose sight of the fact that it is in Russia's interests to solve the problem. It is only a few days until the weekend when all the Heads of Government of the G8 countries will meet in summit; a major part of the agenda should be—and will be—the difficulties of the Russian economy and the need for a closer and better relationship between it and the west. We want to be able to focus on that at the weekend; we know that the Russian Government also want to do that, so there should be good will on both sides to resolve this problem.

Sir John Stanley: Does the right hon. Gentleman agree that, were a separate Russian sector to be created and were the Russian forces in that sector to be placed outside the NATO command and control structure, that would, in effect, amount to a de facto partition of Kosovo that—as the right hon. Gentleman rightly pointed out in his statement—is in no way provided for in the peace solution?

Mr. Cook: The reason that negotiations are continuing and have not concluded is precisely because we stoutly resist such a model—for the very reasons given by the right hon. Gentleman. We should recall that one civil administrator will be responsible for the civilian reconstruction of Kosovo. His or her writ will run through all sectors in Kosovo, and he or she will be responsible

for bringing together one set of political institutions—including election to one, single Kosovo Parliament. Therefore, it is most important that all military commanders, in whatever sector, recognise the objective of working together to create one, single Kosovo under democratic self-government.

Mr. Dale Campbell-Savours: This is the third time in 20 years of my membership of the House that Ministers have come to Parliament to announce, in essence, the routing of the dark forces of fascism in different parts of the world—in the Falkland Islands, in Kuwait and now in Kosovo.
My right hon. Friend referred to economic regeneration. Given that we shall be dealing, in effect, with a de facto international protectorate, and given that the relationship between Kosovo and Serbia will now be strained, is it not now necessary to consider the whole question of the future of the currency? Otherwise, we may well find that the reconstruction of the economy of Kosovo is undermined by the problems that exist in wider Serbia.

Mr. Cook: My hon. Friend is absolutely right to say that, in Kosovo, we have witnessed the defeat of fascism. There was no clearer basis for Milosevic's action than the doctrine of ethnic superiority, which we have now comprehensively defeated.
As for my hon. Friend's question, I am not sure that the first thing currently needed by Kosovo is a central bank. There are an immense number of tasks to be carried out in order to ensure that we repair the physical fabric, rebuild homes and get people back there and into their careers. Of course, as that process develops, it will be necessary to work out an economic reconstruction package. The European Union stands ready to assist with that—so too do other institutions of the world community. In Kosovo, we can develop an economy that will provide lessons for the people of Serbia and bring home to them the extent to which they are both impoverished and deprived of freedoms that are now being taken for granted in the rest of Europe.
Kosovo could be a good model and a useful lesson to help to encourage the forces of opposition in Serbia.

Mr. Tom King: In paying tribute to the achievements of our armed forces and the other forces in NATO, does the Foreign Secretary accept that now is the really dangerous time for them and that the days ahead might pose far greater dangers than any they have faced so far? He calls for an end to ethnic cleansing, and, in the same breath, mentions the scale of the atrocities that are every day being discovered, in the knowledge that they will reinforce in the minds of others the desire for revenge for the atrocities that have been committed against them. Preventing acts of revenge will pose a great challenge to NATO forces.
The right hon. Gentleman proudly paid tribute to the fact that we are making by far the largest contribution to NATO's current land forces, and our forces are likely to remain in the region for some considerable time. Is that predominance of contribution likely to continue?
As for Russia, I have heard some alarming stories of impetuous suggestions—not, I am pleased to say, made by anyone in this country—about how the current difficulties with the Russians might be dealt with. In view


of the confused nature—to put it mildly—of the current Russian Government and the various elements within it, may I strongly suggest that that matter be left to General Jackson for sensible resolution on the ground?

Mr. Cook: I agree absolutely that the issue of the airport is much better resolved by dialogue, which, as far as possible, should take place on the ground among those who can see the situation at first hand rather than from a remote position.
On the question of British forces in KFOR, we expect the large predominance and strong representation of the British in KFOR to be reduced after a number of months, as the rapid reaction corps is no longer needed for KFOR headquarters. We are in the lead during the current operation because we are the designated lead country in the rapid reaction corps.
I strongly share the sentiments expressed by the right hon. Gentleman in his opening remarks. The work is dangerous and no one should underrate the courage needed of our armed forces to enter territory in which there is as yet no secure peace. Our commitment is to create a multi-ethnic, pluralist Kosovo—a place where people of all ethnic identities will feel safe and secure. However, after the past two months of atrocities, that task will be far more difficult than it would have been before. One of the real tragedies for Kosovo and for Serbia is that President Milosevic did not accept the package offered at Rambouillet, which would have given Serbia a better result than it now has, and without any of the pain, bloodshed and brutality of the past two months.

Mr. Tam Dalyell: The right hon. and learned Member for Folkestone and Hythe (Mr. Howard) specifically asked about Kacanik, where the most dreadful things have happened. Could there also be an investigation into the brutal murder in Kacanik on 28 February of the Serb police inspector, Bogulduk Staletovic, who was doing his best to bring ethnic Albanians and Serbs together? What will happen to any member of the KLA who is found to have been equally brutal? What is NATO's attitude now to its obligations to the protection of those innocent Serbs who may themselves be ethnically cleansed?
Finally, during the debate of 25 March 1999, I asked the Foreign Secretary about relations with the Russians, and especially about the valuable work that he was then doing with the governor of Murmansk and others on the millennium bug—[Interruption.]

Madam Speaker: Order. Would the hon. Member whose pager is going off leave the Chamber? Some hon. Member must be guilty. I am sorry, Mr. Dalyell—please continue.

Mr. Dalyell: I was referring to the question of the millennium bug, Murmansk, and the Soviet Arctic fleet. My right hon. Friend the Foreign Secretary replied:
I am confident that they will want to proceed with what they know is a solution to a pressing problem."—[Official Report, 25 March 1999; Vol. 328, c. 540.]
Is that, in fact, being done?

Mr. Cook: Our commitment to protect the people of Kosovo extends to all, including the Serbs. In fact,

the evenhandedness of our forces was demonstrated when the Gurkha Battalion disarmed 70 members of the Kosovo Liberation Army whom it encountered in an armed formation.
As to the murder of the Serb policeman to which my hon. Friend referred, it is the remit of the International War Crimes Tribunal to pursue war crimes of all kinds against all ethnic groups. To be fair, the House should note that the tribunal in Bosnia has indicted Serbs, Croats and Bosniaks without respect to ethnic identity.
Finally, I assure my hon. Friend of my personal commitment to taking forward the work at Murmansk on nuclear waste. I am pleased to say that Igor Ivanov has accepted my invitation to visit Britain as my personal guest, and that issue will certainly be high on our agenda.

Mr. Nicholas Soames: First, will the right hon. Gentleman accept that, while the Russians have been handled without great difficulty, their behaviour has been reprehensible and they have taken up much of the time of General Sir Michael Jackson, who has better things to do than worry about them? When the right hon. Gentleman speaks to the Russians at the weekend, will he tell them not only that their behaviour has been reprehensible, but that he expects to see Russia immediately replace its troops from SFOR who have been sent to Kosovo?
Secondly, will the right hon. Gentleman comment on the use of the airport at Pristina? Despite the Russians' presence, can it be used for all forms of military transport and aircraft? If so, will the right hon. Gentleman consider moving one or two of the Harriers so that they might be used sooner? Thirdly, when will the right hon. Gentleman be able to comment more precisely on the disarming of the KLA?
Finally, has the right hon. Gentleman considered speaking to the building industry in this country to see whether it might lend the development service some of its experts on rebuilding? The chaos that will face the refugees upon their return to Kosovo will be terrible to behold and they simply will not know where to begin.

Mr. Cook: I agree absolutely with the hon. Gentleman's last point. All European nations will have to contribute to ensure that we can rebuild Kosovo before winter, and I am sure that the British building and construction industry will be willing to play its part.
The hon. Gentleman expressed certain views about Russian behaviour, but he will understand that it might not necessarily be helpful for me to confirm whether I share that sentiment. We are concerned about the Russian situation, which has consumed a lot of time that we could have devoted to other parts of the Kosovo crisis. I thoroughly endorse his point that the Russians' unilateral arrival in Kosovo is as unfortunate and unhelpful as their unilateral departure from SFOR, where a gap has been left in the Bosnian forces.
We have no present requirement for the airport, nor do we plan to use it. However, it is important that, in the fullness of time, the airport be brought back into use for all members of KFOR and be operated on a multinational, not simply national, agency basis.

Ann Clwyd: My right hon. Friend knows that I supported the aims of NATO throughout the


war. I obviously support the reconstruction of Kosovo and the assistance that we will give that country and its people. I hope that economic assistance will also go to Montenegro, Albania and Macedonia. Will my right hon. Friend re-examine the decision not to assist Serbia until Milosevic is got rid of? I want to see Milosevic brought before a war crimes tribunal so that he can answer for his war crimes and other crimes against humanity. However, at the same time, I believe that Serbia will join the community of nations faster if we show a willing hand in assisting it to reconstruct and rebuild Serbian lives.

Mr. Cook: I thank my hon. Friend for the consistent support that she has given to our campaign and to our objectives, which she has expressed at all times in the past 10 weeks. I am glad that my hon. Friend mentioned Montenegro because it gives me an opportunity to underline our commitment to that country. President Djukanovic and his Government demonstrated tremendous courage and steadfastness, despite pressure from Belgrade, in bravely standing out against Belgrade's policies and in opening their borders without restraint to refugees from Kosovo. Our agreement with the Serb forces makes it plain that they must withdraw to Serbia, not to Montenegro, and we shall continue robustly to support the democratic Government in Montenegro.
On support for Serbia, a distinction will have to be made. We want to help the people of Serbia. They, too, face the problem of the coming winter, and we must be prepared to provide humanitarian relief where it is necessary and appropriate. But the international community cannot become involved in major economic reconstruction of Serbia while the country is led by the present Government, if for no other reason than that their economic policies would make any such attempt futile and might well result, as in the past, in much of the money that should be spent on Serbia ending up in foreign bank accounts that do not belong to the people of Serbia.

Mr. Bowen Wells: Which bank account has the £50 million for the relief of refugees, which I very much welcome, come from? Has it come from the Treasury contingency reserve or the reserves held by the Department for International Development? To whom will that money be given and for what purposes? Is it intended to provide prefabricated housing to enable returning refugees immediately to reoccupy their ruined villages and towns and begin reconstruction—and possibly to be part of the work force?

Mr. Cook: The money has just been announced and we have not yet earmarked how all that £50 million will be spent, but we shall take that forward in consultation with agencies, particularly the UNHCR. I am advised that the money comes from DfID's reserves and will therefore be provided without any cost to DfID's programmes in Africa, Asia and poorer countries.

Mr. David Winnick: Will it be possible for a report on war crimes to be presented to the House and placed in the Library so that the crimes, rapes and atrocities that have taken place can be understood not only by us, but by generations of parliamentarians in the

next century? They would then be able to understand why the operation took place and why it was so essential that Kosovo be liberated.
I want to ask my right hon. Friend a question about a matter that he has touched on before. What reassurance can be given, as soon as possible, to Serbian civilians in Kosovo that NATO troops are there as an international force to protect all, and that we will not tolerate any pogroms or persecution of Serbians because we are there to protect all communities?

Mr. Cook: I am happy to repeat my earlier assurances that our commitment is to protect all people in Kosovo, whatever their ethnic identity. Our objective is to create not a single ethnic state, but a multi-ethnic state under the democratic rules and values that we understand.
I shall consider my hon. Friend's request for a report on war crimes and find out whether we can respond to that in the fullness of time. It is important not only that we know what happened in Kosovo, but that the people of Serbia know what happened. Too many of them are still ignorant of what was done in their name in Kosovo, and I am sure that if they fully understood that they would share our repugnance and revulsion. That education is probably an important part of putting Serbia on the road to democracy and freedom.

Mr. Douglas Hogg: What proposals does the right hon. Gentleman have for the political reconstruction of Kosovo? I am sure that he agrees that there should be an elected Albanian-Kosovar authority in Kosovo as soon as possible. I recognise that it is difficult to have elections before the refugees return, but could he tell the House what proposals he has for the creation of a democratic body in Kosovo? In the meantime, whom does he regard as having authority to speak on behalf of the Albanian Kosovars? Is it Mr. Rugova, is it the head of the Kosovo Liberation Army, or is it someone else; and on what basis does that person have authority?

Mr. Cook: The short answer to the right hon. and learned Gentleman's last question is that it is not for me to decide who speaks for the Kosovo Albanian community. It is for those in that community to decide. Our commitment is to provide a democratic process, with guaranteed free and fair elections, in which they can decide for themselves who they wish to speak on their behalf. In the meantime, until we can achieve that, it would be helpful if all those representatives of Kosovo Albanian opinion were to work together to help us to co-operate with them in the salvation of Kosovo.
On the political structure, the terms of the Security Council resolution are explicit: a political settlement should take account of the Rambouillet accords. They provide for an elected Parliament of Kosovo. To correct the right hon. and learned Gentleman, they provide not for an Albanian Parliament but for a Parliament representing all the ethnic groups in Kosovo. The OSCE will be charged with the duty of carrying out elections for the creation of that Parliament. We will seek to proceed with that as quickly as is reasonable, but it will not be done overnight. The simple task of creating an electoral register in Kosovo following the past two months will itself take some months.

Mr. Robert N. Wareing: Should we not be rejoicing at the presence of Russian


troops in Pristina and Kosovo because it not only gives the Serb population in Kosovo a sense of security, but underlines Russia's feeling that ethnic cleansing should go no further in the province? In view of my right hon. Friend's statement that he wants more Russians in Kosovo, should he not be making representations to the Government of Hungary to ensure that Russian troops can be taken into Kosovo, overflying Hungarian airspace?

Mr. Cook: The Government of Hungary, as a member of NATO, will of course permit overfly as and when there is agreement with NATO for those troops to arrive in Kosovo. I reiterate that I would welcome a strong Russian contribution to Kosovo and to the Kosovo force, but the time for rejoicing will be when we have the agreement that enables those Russian troops to take part in an integrated operation with a unified chain of command.

Several hon. Members: rose

Madam Speaker: Order. We must now move on.

NEW MEMBER

The following Member made the Affirmation required by law:

Hilary James Benn Esq., for Leeds, Central.

Points of Order

Mr. David Rendel: On a point of order, Madam Speaker. You will be aware of today's planted written question, which has already been answered, on the habitual residence test and its future. Is it not very wrong that, only a few weeks ago, the Government rejected an amendment to the Welfare Reform and Pensions Bill that would have achieved very much the same as today's answer? Is it not also wrong that, given that the matter affects the right to benefits of 20,000 people every year and will save the Government some £20 million a year, the Government decided to release the information in a written answer, rather than making a full statement to the House, which would much better have enabled those whose rights are at risk to realise what is happening?

Madam Speaker: As the hon. Gentleman is aware, it is for Ministers to decide whether to make such announcements by oral statement or by written answer. No doubt the hon. Gentleman, who I know has a keen interest in this, will find ways of following up this issue through the procedures of the House in due course.

Dr. Evan Harris: On a point of order, Madam Speaker. The House has a great interest in issues relating to the sexual health of teenagers and the education and welfare of single parents. In recent weeks, there have been many opportunities for the Government to present on the Floor of the House their policies on that matter. Although a planted question was answered by the Prime Minister today, is it in order for the Government to leak the information to the newspapers, and to write an article for a newspaper this morning, before presenting the information to the House in a written answer or, preferably, in a statement, so that hon. Members on both sides of the House may hear those important matters first and have an opportunity to question the Government on them?

Madam Speaker: I am aware that the Prime Minister has answered a written question on this issue today. If there has been advance publicity about this, I most strongly deprecate it. Any such publicity could certainly have waited until tomorrow, as far as I am concerned.

Orders of the Day — Health Bill [Lords]

As amended in the Standing Committee, considered.

New Clause 18

Orders of the Day — ENGLISH AND SCOTTISH BORDER PROVISIONS

'.—(1) Her Majesty may by Order in Council provide for any functions to which subsection (2) applies which are specified in the Order, so far as exercisable in respect of the provision of services to persons in English border areas, to be exercisable (instead of any corresponding function to which subsection (4) applies) in respect of the provision of the services in question to persons in Scottish border areas who are specified in the Order.

(2) This subsection applies to any functions under the 1977 Act, or Part I of the National Health Service (Primary Care) Act 1997. which are exercisable by the Secretary of State or any Health Authority or Primary Care Trust.

(3) Her Majesty may by Order in Council provide for any functions to which subsection (4) applies which are specified in the Order, so far as exercisable in respect of the provision of services to persons in Scottish border areas, to be exercisable (instead of any corresponding function to which subsection (2) applies) in respect of the provision of the services in question to persons in English border areas who are specified in the Order.

(4) This subsection applies to any functions under the 1978 Act, or Part I of the National Health Service (Primary Care) Act 1997, which are exercisable by the Scottish Ministers or any Health Board or NHS trust established under the 1978 Act.

(5) In this section—
English border area" means the area of any Health Authority adjacent to Scotland,
Scottish border area" means the area of any Health Board adjacent to England.'—[Mr. Denham.]

Brought up, and read the First time.

The Minister of State, Department of Health (Mr. John Denham): I beg to move, That the clause be read a Second time.

Madam Speaker: With this, it will be convenient to discuss Government amendments Nos. 46 and 47.

Mr. Denham: This is the first debate of the Report stage. We had lengthy considerations Upstairs in Committee, and I am sure that we shall cover some of the same ground today.
This new clause and the amendments consequential upon it will enable sensible provision to be made for local health care services at the border between England and Scotland. It is intended that similar provision will be made at the border between England and Wales, but that does not require primary legislation.
Several GP practices located near the England-Scotland border have patients on their lists from both sides of the border. Under the existing arrangements, that means that the general practitioners concerned are part of both the English and the Scottish national health service systems. In commissioning services, in particular, that has created additional burdens on border GPs, which take up time, energy and resources that might be better devoted to

patient care. For example, one practice reported having to liaise with six different teams of community staff to cover its scattered population.
The new clause will enable a GP practice and its patients to be dealt with by either an English health authority or a Scottish health board, instead of having to be dealt with by both. Provisions have been made in England at the boundaries between health authorities so that all the patients registered with a GP practice have their services commissioned by a single primary care group. That enables a more coherent approach to be taken to the planning of local health services, simplifies local administrative procedures and avoids duplication of time and effort.

Mr. Michael Fabricant: Would the Minister be kind enough to clarify whether these provisions have been brought forward primarily because of the introduction of primary care groups, and whether, if fundholding had remained, these provisions would have been unnecessary?

Mr. Denham: No. I understand that the problem that we are dealing with dates back to the introduction of commissioning in the early 1990s. At the moment, it affects relatively few patients and GPs; none the less, it is a problem for them.
As the effect of an order under the new clause will be to confer on the Secretary of State or English health authorities the ability to operate in relation to Scottish patients, and for Scottish Ministers and Scottish health boards to operate in relation to English patients, both Westminster and the Scottish Parliament will be able to scrutinise, debate and approve the order. Amendment No. 47 provides that the Order in Council must be laid before, and approved by resolution of, both Houses of Parliament and the Scottish Parliament.
Although relatively few patients will be affected by these provisions—about 3,500 on current estimates—they are important in ensuring that sensible, practical arrangements can be made for the provision of health care in border areas. We have consulted those who will be most affected by the provisions—health authorities, health boards and GPs in cross-border areas—and everyone who responded was in favour of the approach that we propose to take.
I commend the new clause to the House.

Mr. Philip Hammond: The Minister outlined this rather late Government new clause and presented it merely as a tidying-up exercise that would extend to the border between England and Scotland the arrangements already in place for dealing with primary care groups whose populations straddle borders between health authorities in England.
I accept the Minister's underlying premise that practical and administrative difficulties arise for general practitioners whose practices deal with populations in different health authority areas, and that as a consequence they may have to deal with a multiplicity of commissioning arrangements. It is right in principle that we should seek to address GPs practical concerns in a


way that ensures that the service delivered to their patients is effective, meets their patients' expectations and is seamless in its presentation.

Mr. Fabricant: Does my hon. Friend agree that one of the problems that arises from the border areas is the disparity between the amounts of money paid per capita for patients in Scotland, as against those in England?

Mr. Hammond: I thank my hon. Friend for that comment. He anticipates an issue that I shall come to in a moment.
Let me set the matter in the context of the considerable pressure on general practice throughout the country—by that, I mean the United Kingdom. The position is no different in Scotland from that in England. Indeed, there is evidence that GPs in Scotland particularly have been feeling the strain over the past few months.
Over the past year, since the Government made widely known their plans for the reorganisation of primary care in the United Kingdom, general practitioners have been alarmed and disconcerted about the prospects for their future. They have been concerned about the sanctity of their status as independent contractors to the national health service, and they have been alarmed on behalf of their patients about their continuing ability to supply the range of services that those of them who were fundholders were privileged to be able to provide under the fundholding regime.
The Government have gone a considerable distance to reassure GPs about their intentions for the future of general practice services. Hon. Members who were privileged to be members of the Standing Committee that considered the Bill will by now be familiar almost verbatim with the terms of a letter written on 17 June 1998 by the Minister of State's predecessor to the chairman of the general practice committee of the British Medical Association. That letter was written in response to the widespread concerns of GPs that the move to primary care groups would impinge upon their freedom to prescribe and refer as they thought fit.
The reason that I raise the matter now is that, despite probing at some length in Committee, we were unable to ascertain whether the commitments made by the Minister of State's predecessor in that letter to GPs in England and Wales were binding in respect of GPs in Scotland. The new clause deals with the situation in which GPs in Scotland may be treating English patients, and GPs in England may be treating Scottish patients.
The tone of the letter of 17 June was reassuring. The Minister's predecessor wrote:
The ability to offer patients the individual care they require has been and remains the cornerstone of general practice. The new system allows individual GPs to decide what is best for the patient, whether for example to prescribe drugs or refer patients to hospitals, in the light of their clinical judgement. Patients will continue to be guaranteed the drugs, investigations and the treatments they need.
The Minister went on to state:
There is no question of anyone being denied the drugs they need because a GP runs out of cash.

That comment is made in the context of the new unified budgets for primary care trusts, which will succeed primary care groups in due course. The Minister concluded that paragraph by stating:
I can guarantee that the freedom to refer and prescribe remains unchanged.
4.30 pm
The difficulty that I and my colleagues who were members of the Standing Committee faced was that although the Minister was able to give assurances that the commitments made in the letter, which referred explicitly and specifically to primary care groups—the precursors to the primary care trusts that will eventually succeed them—would apply also to the trusts when they came into being and would be equally valid, it was not possible for him to give the Committee any such satisfactory assurance with regard to Scotland. As is clear under the arrangements in the Scotland Act 1998, and given the Bill's provisions relating to devolution, it will be for Ministers in the Scottish Executive to make such commitments and to give such binding undertakings.
There are concerns in the GP community on both sides of the border; there are also considerable morale and recruitment problems. We have additional concerns about the position of general practitioners in Scotland. The new clause clearly highlights the potential divergence between the delivery of health services in England and in Scotland. The Minister is creating a population of people who will live and belong in one country but be treated under the rules of the other country.
When the Minister replies to this short debate, perhaps he will confirm that what I have just said is correct and that when an English person is the patient of a Scottish general practitioner and crosses the border into Scotland for treatment, he will be treated under the rules and regulations pertaining in Scotland, not those pertaining in England. In that sense, that patient would be in a distinctly different position from a national health service patient who is treated at NHS expense in a private hospital, where, notwithstanding the fact that he is not in an NHS hospital, the NHS regime for ensuring quality that is in place in the NHS extends to and covers that patient during the period that he spends in a private hospital. It would be useful if the Minister could confirm my understanding that the rules and regulations and the regime of the country where the GP is located will govern the treatment.
That is not an empty question. At present, in many respects the systems and the services are similar on both sides of the border. However, it is possible—in my view and in the view of my right hon. and hon. Friends, it is quite likely—that over time differences will evolve in the regimes that operate north and south of the border. Those differences will be possible because of the responsibility that Scottish Executive Ministers will have in relation to non-reserved health matters and because of the serious discrepancy to which my hon. Friend the Member for Lichfield (Mr. Fabricant) has already drawn attention in the per capita spending on health services north and south of the border.

Mr. Fabricant: My hon. Friend the Member for Altrincham and Sale, West (Mr. Brady) has reminded me that there are fund-raising or tax-raising powers in the Scottish Parliament. Discrepancies between the amounts


of money being spent per patient in Scotland as opposed to those in the rest of the United Kingdom could be increased if the Scottish Parliament were to charge 3p extra on income tax.

Mr. Hammond: My hon. Friend is right to observe that, even under the existing block grant system, per capita spending in Scotland is significantly higher than in England, but, as he says, it would be possible for the Scottish Parliament to raise health spending in Scotland still further. If it were minded to do that, given that health is a devolved matter and its responsibility, that would be a legitimate political decision for it to make in the light of the expressed views of the Scottish people. I do not think that we in this place would question its right to do that.
We are considering a situation in which the evolution of divergent services between the two countries, north and south of the border, could accelerate and could become an issue. I shall give the House an example of one of the areas that we explored recently in Committee, about which I had the privilege of asking the Minister some questions.
It is clear that professions supplementary to medicine which are not already regulated under the present system, but fall to be regulated under the Bill, will be subject to regulatory regimes which can be different north and south of the border. It will be perfectly possible for such professions to have different regulatory regimes, under which someone who is entitled to practise north of the border might not be entitled to practise south of the border. It is important that we recognise those possibilities and the fact that discrepancies could occur over time.
One of the most important changes that the Government will introduce to the national health service through the Bill relates to the duty of quality, which is imposed on all health service bodies, and to the duty of co-operation, which is imposed as a statutory duty between health service bodies and between health service bodies and local authorities. We do not disagree in principle with the imposition of a duty of co-operation—it sounds sensible and we have had an opportunity to explore how well it will work in practice—but the duty of quality will be enforced in England and Wales primarily by the activities of the Commission for Health Improvement, which will have a wide-ranging remit to examine NHS bodies' implementation of their quality programme and the way in which they are interpreting the guidelines of the National Institute for Clinical Excellence.
The remit of NICE does not extend to Scotland, however, so once again there will be a discrepancy between the regimes operating in England and in Scotland. Conservative Members will be greatly interested to know what arrangements the Minister intends to put in place to ensure that people who cross the border for treatment or for diagnosis are not in any way caught in the gap between two different regimes.
The remit of NICE will include looking at the clinical and cost efficiency of various drugs and treatments that are, or will perhaps become, available in the NHS. Subject to not anticipating later debates, let us assume that the Bill will remain unchanged, and that the remit of NICE will

thus remain unchanged. Yet another problem will arise in respect of the English-Scottish border: once NICE has deliberated, reported and made its recommendations on the appropriateness of a making a drug or a treatment available with regard to its clinical and cost effectiveness, reality will bring us sharply up against the wide discrepancy between per capita funding of the NHS in England and in Scotland.
NICE cannot operate in a vacuum. It is not realistic to assume that the judgments that it may sensibly make in relation to England can be equally applicable in Scotland, where the NHS is differently funded. In case anyone thinks that the differences are minor or insignificant, I shall give the figures, which are interesting. In 1999–2000, expected per capita NHS expenditure in England is £802, whereas in Scotland it is £964.

Mr. Malcolm Chisholm: That point has been made several times already, and may be made many more times before the night is out. Does the hon. Gentleman recognise that public expenditure should be related to need? If so, does he accept that all the major health indicators show that Scotland is a more unhealthy nation than England?

Mr. Hammond: I would accept the need element, but if one looks around the English regions, it quickly becomes apparent that the regional distribution of NHS expenditure does not directly reflect need, as the hon. Gentleman suggests it should. I am trying to identify the implications of the different funding per capita in the national health service north and south of the border for the effective functioning of these apparently innocuous cross-border arrangements.

Mr. Fabricant: I should not like my hon. Friend to be misled into thinking that areas of deprivation exist only in Scotland. Last Friday, I attended a meeting of the primary health care group in Salters Meadow centre, Rugeley road, Chase Terrace, which became part of my constituency after the boundary change. My hon. Friend may be surprised to know that the standard mortality rate for Chasetown men suffering from heart disease is 207, which is more than twice the national average. The saddest thing of all is that the local Hammerwich hospital, which serves people from Burntwood, faces the possibility of closure as a direct consequence of the abolition of fundholding practices and the introduction of primary care groups. Is not that a disgrace?

Mr. Hammond: I agree with my hon. Friend: it is, indeed, a disgrace. Hon. Members will know of many local pockets of deprivation and health need around England and Wales that are not being dealt with consistently. We are faced with a discrepancy between per capita spending in England and Scotland of a fraction under 20 per cent. On the Government's own estimates, that figure is not intended to go down: it will stay approximately stable. Those planning the delivery of health care in Scotland will have significantly greater latitude than those charged with the task of planning health care in England and Wales. That cannot but have an impact on the systems, and on the availability of treatments and drugs.
The Minister may have a different view, but I cannot see any way in which the proposed cross-border arrangements could be anything other than one-way


traffic. I do not imagine that many Scottish patients will want to be under the regime that will operate in England, given the much tighter financial constraints that it will face. The 20 per cent. difference—£160 per capita—extrapolated across the country would have a huge effect on waiting lists in a typical English parliamentary constituency. It is a significant factor relating to the delays experienced by constituents of hon. Members with English and Welsh seats who are waiting for treatment, and those being told that treatment is not available to them.
I should be interested to hear from the Minister what additional arrangements to deal with the differences in the regulatory structure will be needed to protect patients who are involved in cross-border arrangements.

Mr. Graham Brady: Before my hon. Friend finishes, I wonder whether he could shed some light on a potential problem with the new clause. Is it not possible for someone to opt to enjoy the Scottish arrangement at one time and the English arrangement at another? Would the clause not institutionalise a situation that the health authorities in the border regions could exploit by offering some services to a lower standard in the knowledge that the people in their areas could just as easily go over the border and benefit from different provision?

Mr. Hammond: My hon. Friend raises an interesting point to which the Minister should reply. I suspect that the Government's intention is that the arrangements should deal with patients who live in a different country from the practice where they are registered.
My hon. Friend's point brings us to initiatives such as walk-in consultation centres, which the Government favour. A variety of other cross-border issues will arise in decisions on where a person belongs and what that entitles them to. If figures are available, will the Minister tell us how many people will be affected? A finite number of people will be involved in GP practices that already have a cross-border element. Has the Minister made an estimate of what the number might rise to as a result of the incentives that the new clause, which I am confident will be incorporated in the Bill, will give patients on the English side of the border to manipulate the arrangements?
Finally, subsection (2) says:
This subsection applies to any functions under the 1977 Act".
The Minister was kind enough to write to my right hon. Friend the Member for Maidstone and The Weald (Miss Widdecombe) during the closing stages of the Standing Committee. He said that he intended to make provision for the exercise of health service functions across the England-Scotland and England-Wales borders; that the new clause would be designed to put existing practice on a firmer legal footing; and that provision would be made for the exercise of functions under part I of the National Health Service Act 1977 in relation to GP practices that straddle such borders. What is the significance, if any, of the decision to exclude from the new clause the reference that the Minister was expecting to make to part I?

Mr. Fabricant: As my hon. Friend has already said, doctors are alarmed and concerned about the outrageous fact that fundholding practices have been abolished before the Bill is enacted. I shall not on this occasion read at length—there might be opportunities later, in the early hours of tomorrow morning—from an e-mail that I have received from a local doctor. The hon. Member for Tyne Bridge (Mr. Clelland) smiles, because he knows that a number of doctors in Lichfield have access to e-mail and they e-mail me frequently on the issue. I shall simply quote the first line:
All right, primary care groups do now exist, but there are still more questions than answers.
That also applies to new clause 18.
When I asked the Minister whether the new clause would have been necessary under fundholding, he answered yes. He said that it was a simple tidying-up mechanism, but, if so, why has it been introduced at such a late stage? Are the parliamentary draftsmen at fault? Is the Department of Health at fault? Why has it been introduced at the final stage?
New clause 18 will amend the National Health Service Act 1977. In Committee, my hon. Friend the Member for Runnymede and Weybridge (Mr. Hammond) pointed out the strange architecture of the Bill. It is so peculiar and difficult to see through that the Department had to produce a consolidated Bill to incorporate the 1977 Act, of which they printed only two or three copies, so that we could attempt to follow how the Bill and previous Acts will be amended. I cannot but be suspicious that the reason for the Bill's strange architecture is to confuse the Members of Parliament who have to scrutinise the legislation and the doctors.
It is also typical that new clause 18 states in the first line:
Her Majesty may by Order in Council provide for any functions to which subsection (2) applies".
In other words, yet again a blank chequebook is being given by a Bill that contains no detail. Issues will be determined Upstairs in the privacy of a Standing Committee on Delegated Legislation by only a few Members of Parliament and under a time limit.
The Bill is confused, both in its structure and in what it is trying to achieve. The Bill mentions English border areas and Scottish border areas, but it gives no clear definition of those areas. Does it mean five miles either side of the border, or 10?

Mr. Denham: It might be helpful if I point out that subsection (5) of new clause 18 defines English and Scottish border areas in terms of the health authorities and boards adjacent to the border.

Mr. Fabricant: That is helpful. The Minister is, as ever, well informed, but will patients in the area feel that their position has been clarified? As my hon. Friend the Member for Altrincham and Sale, West (Mr. Brady) said, patients might find it beneficial to cross the border into Scotland. My hon. Friend the Member for Runnymede and Weybridge gave some figures that suggest that they might. He pointed out that £802 per capita is spent on health care in England and Wales, whereas £964 is spent in Scotland. That shows the differential.
The hon. Member for Edinburgh, North and Leith (Mr. Chisholm) said that there is greater deprivation in Scotland than in England, and perhaps that is so in


general, but there are pockets of deprivation in England and Wales, just as there are pockets of great wealth in Scotland. During the war, my mother was posted to Morningside in Edinburgh, which I believe is quite a wealthy area.
In Chasetown in my constituency, the standard mortality rate generally is 160 for men, which is 1.6 times the national average, and 142 for women. The SMR for heart disease in Chasetown is 192, almost double the national average. The figure for men is 207, and for women 196. The main causes of death are congenital factors, accidents and cancers. To say that such conditions exist only in Scotland would be a huge travesty of the truth.
Why are the moneys being spent in Scotland not also being spent at the same rate in deprived areas of England and Wales?

Mr. Chisholm: The hon. Gentleman has not completely understood what I said. I made a simple point about headline health indicators for Scotland as a whole compared with England as a whole, whereas he is making an entirely different point.

Mr. Fabricant: I am grateful for that clarification. I thought that the hon. Gentleman's point was that Scotland deserves extra money because it is deprived in comparison with England and Wales, with more disease and higher mortality rates. I think that he is now nodding in assent. I am making the same point: deprivation should be taken into account, not only in Scotland but in England and Wales.
Do not we have a national health service? Instead of the service being truly national, serving Scotland, England, Wales and Northern Ireland, it is becoming fragmented and unfair. If an individual is suffering from a complaint, he may be more likely to receive better treatment in Scotland, where more money is available, than in the rest of the United Kingdom. Is not that wrong? Should not money follow the patient, not the nationality?

Dr. Howard Stoate: Have not we always had differential spending on health care, depending on circumstances? The resource allocation working party in the 1980s made it clear that money should be allocated in different areas according to need. We currently use Jarman indices to make deprivation payments available to general practitioners. It is wrong to be hung up on the idea that Scotland gets all the money, because different regions have always had different amounts available, dependent largely on need.

Mr. Deputy Speaker (Mr. Michael Lord): Order. Let us not go too far down the road of regional differences. I remind the House that we are talking specifically about arrangements at the border.

Mr. Fabricant: I am grateful for that guidance, Mr. Deputy Speaker.
I agree with the hon. Member for Dartford (Dr. Stoate), who is a GP. However, he reinforces my argument, which is that money should follow need. It should not be allocated according to deals that favour other countries in

the United Kingdom over English regions. Why should 20 per cent. more money be available, per capita, in Scotland than in England and Wales? It is not because of need or deprivation, but because of Scottish Office deals with the Treasury.
5 pm
Patients and doctors will have an incentive to use new clause 18 to move from one part of the borders region to another simply to get extra money and care. Who could blame them? Should not parents expect the best care for their children? If that means crossing the border, they will do so. However, as the hon. Member for Dartford said, money should be allocated according to need. It was a shame that the hon. Gentleman—in whose constituency, incidentally, there was a Tory gain in last Thursday's elections—chose not to be a member of the Committee considering the Bill. He is a GP, and his input would have been valuable, but perhaps the Whips decided that he should not be on that Committee—

Mr. Deputy Speaker: Order. The hon. Gentleman must return to the new clause.

Mr. Fabricant: The new clause is confused. As I said, it is not explicit, and the detail will have to be dealt with by an Order in Council. Much is left to the imagination, and the fear is that the Government will take advantage of that lack of detail when they want to make financial cuts.
We have been led to believe that Scotland will enjoy better health care because of devolution, yet a clause in the part of the Bill that deals with Scotland, to which I shall return later, provides that, under the terms of devolution, the Bill can override legislation passed in the Scottish Parliament. It is clear, therefore, that the Government are merely paying lip service to devolution. They are interested in the soundbite and the general principle, but the Bill allows them to overrule the Scottish Parliament in this matter.
Finally, in our deliberations in Committee, a number of acid tests of the Bill emerged, and one is relevant to the new clause. The Government said that they would abolish fundholding. All the GPs in my constituency were fundholders, and so were able to send patients where they could get the best treatment locally. That secured the future of the two local hospitals in my area, the Hammerwich hospital in Walsall and the Victoria hospital in Lichfield.
We asked the Government to include an acid test in the Bill. The Government had said that primary care groups would not mean a reduction in service, so we asked them to include a clause requiring the publication each year of the details of any service that would be withdrawn or added as a result of the replacement of fundholding with PCGs. That would have tested whether PCGs were improving the health service, and new clause 18 would be less relevant. The Government tacitly admit that the abolition of fundholding and the introduction of PCGs will mean a reduction in service, which is why they are introducing new clause 18.
Patients in border areas may have to cross borders, which would not have been necessary under fundholding. The position became clear in Committee. The Minister chanted the mantra—we have heard it from the Secretary of State—that fundholding was unfair and a two-tier


system. We suggested that every doctor should be made a fundholder, but we were told that that would be too expensive. That is an admission that fundholding was about excellence, just as grammar schools were. We cannot afford to make all doctors fundholders, so the 60 per cent. of patients who were treated by fundholding practices—practices abolished even before the Bill has been enacted—will instead receive a second-class service.
The hon. Member for Dartford is scribbling hard and may wish to take part in the debate. On the other hand, he may be told by his Whips to keep quiet. Why was the hon. Gentleman never a fundholder? The answer is ideology, not his patients' needs. He should come to Lichfield to meet my doctors.

Miss Ann Widdecombe: Do not ask him to do that.

Mr. Fabricant: I should invite the hon. Gentleman to come while he is still a Member. After the next election, if last night's European results are anything to go by, he will not still sit for Dartford.

Dr. Stoate: My practice never became a fundholding practice because it realised that that system was bad value for money and it did not give patients a good deal. On a point of information, the hon. Gentleman may wish to know that general practitioners in Dartford formed one of the first pilot groups for the switch to primary care groups. About 50 per cent. of those GPs were fundholders, but they voluntarily relinquished fundholding because they realised that PCGs offered far better services for patients in Dartford and Gravesham. By doing so, they provided an extremely effective PCG a year ahead of anyone else. It is providing far better services at far better value for money than any fundholding practice did. That is why the Government are not keen on fundholding.

Mr. Fabricant: GPs know one thing: Labour's huge majority allows the Government to jackboot any legislation through the House. They knew that fundholding would be abolished—

Mr. Deputy Speaker: Order. This debate is not about the merits of fundholding. Would the hon. Gentleman please return to the new clause?

Mr. Fabricant: The introduction of new clause 18 at such a late stage is typical of the way in which the Bill was drafted. Clauses were added at the last minute in Committee, and the new clause—the Government call it simple tidying up—is also being added at the last minute. It is impenetrable, referring to the Bill and to preceding legislation. Yet again, we find a lack of detail. Instead, huge powers are given to the Secretary of State to make decisions Upstairs. Who can wonder that GPs are disturbed? Who can wonder that they doubt the Government's motives? Most important of all, who can be surprised that a MORI poll has shown that 30 per cent. of the population now know that the national health service is not safe in the Government's hands?

Mr. Brady: Such was the rousing reception with which the speech by my hon. Friend the Member for Lichfield (Mr. Fabricant) was greeted, Mr. Deputy Speaker, that I could hardly hear that I was being called to speak.

However, the reception was highly deserved as my hon. Friend made an important contribution to the debate. My contribution will be more technical and I will deal with some of the detail of the new clause.
It would be unwise to suggest that I disagree with your suggestion that the debate should be concerned with the border, Mr. Deputy Speaker, but in my view it is not merely about the border areas but about changing the location of the border for certain purposes. The new clause gives rise to grave concern because of the provision for an Order in Council with all that that implies. When the Minister responds, I would welcome some real detail about what the Government intend to put in the order, and therefore, about the implications for people who live in the border area, whether on the Scottish or the English side.
My concern is that for the purpose of primary health care in particular a different border will be applicable. It is not the border that divides England and Scotland, which is obviously one to which people who live near it have grown used and which has a historical basis. People are comfortable with that border. However, the new clause would change the border. For health purposes, the real border will be that of the health authority area adjacent to the border with Scotland.
The new clause would not simply make arrangements relevant to what happens on one or other side of the border, but would in some ways blur the border between Scotland and England. The critical difference in the treatment that a patient receives will no longer depend on whether he lives on the side of the border that benefits from the Barnett formula and the increased health expenditure to which the broad mass of people in the United Kingdom have been happy to consent for a long time. It will depend on whether people live within the boundaries of the health authority or health board that abuts the border on the Scottish side. That provision has grave constitutional implications and it also has implications for the treatment and funding of health care for the people concerned.
As my hon. Friend the Member for Lichfield sought to suggest, expenditure on health care for the citizens of the United Kingdom differs. It depends on where they live and on the GP with whom they are registered. Due to accidents of geography, there is a question mark over the treatments that people can receive in certain areas. I do not want to stray too far away from the border, but I recently dealt with a constituent who was being denied a treatment that his consultant had told him was essential for his future health. Had he lived on the Manchester rather than the Salford and Trafford side of the health authority boundary, he would have been allowed that treatment.
In the new clause, the difference is writ large—it is between those health authority areas that are English and have roughly 20 per cent. less funding to spend on their residents and those that are Scottish.
We now also have a new distinction between health authorities that have the benefit of abutting the border and those that do not. If the health authority area is at one remove from the border, it will have less flexibility in the planning of its arrangements for the provision of treatment for its residents than if it is directly adjacent to the border. In the planning of treatments that might be discretionary and might contain some element of choice—whether


handed down by the national institute that will be created, or lying within the discretionary decisions currently taken by health authorities—there will be instances in which a health authority could decide that a form of treatment is too expensive to constitute good value. However, that would not be a problem for residents of that area who could cross the border to Scotland where such treatment might be available, at taxpayers' expense. That treatment would be denied to people living on the English side of the boundary.

Mr. John Bercow: I am grateful to my hon. Friend for giving way because he is making a powerful speech. Does he agree that the phenomenon of differential treatment by postcode that he describes has no basis either in logic or in equity? Does he experience in his constituency of Altrincham and Sale, West the same backlash against that injustice that I experience in my Buckingham constituency?

Mr. Brady: I think that I am probably experiencing the same kind of response as my hon. Friend. More often than not, it comes down to the fact that, if there appears to be a danger that adverse publicity will arise from treatment being denied, then treatment is provided, whereas if a person is prepared to suffer in silence, treatment may never be provided. That is a real concern. It is also a concern that relates to waiting list figures, which, of course, are being massaged throughout the whole country. Many health authorities have a miraculous ability to find it in their powers to treat a patient who makes a bit of a fuss about a long delay in receiving treatment. That is nothing short of a scandal; we are beginning to see a different standard of treatment and certainly a different length of waiting time for treatment, depending on the area in which one lives or on whether one is prepared to make a fuss.

Mr. Hammond: Has my hon. Friend observed—as I have—that the most effective way to move oneself up the waiting list is to get one's name mentioned in the Chamber?

Mr. Brady: I am reluctant to be drawn on that point.

Mr. Deputy Speaker: Order. We are again straying a long way from arrangements on the border. Will the hon. Gentleman return to them?

Mr. Brady: That is why I was reluctant to be drawn by the question of my hon. Friend, Mr. Deputy Speaker.
In relation to the specifics of the new clause, we are exacerbating the situation. We are enshrining in law that it will be not merely a matter for health authorities—depending on where they are in the country—to provide different levels and types of treatment at different costs, but that there will also, in effect, be a statutory system allowing individual patients to make choices that exploit the inevitable anomalies in the treatment systems available. A patient might have the choice of registering with one GP practice or another, or might be able to register with an English GP or a Scottish one. A patient

might register with an English GP, but will be aware that Scottish health care facilities may, none the less, be available to him. That is one of the serious question marks over the way in which the new clause was drafted.
The point made by the Minister when he replied to the question put by my hon. Friend the Member for Lichfield relates precisely to the question of which areas the measure applies to. The Minister is right to point out that subsection (5) states:
'English border area' means the area of any Health Authority adjacent to Scotland,
'Scottish border area' means the area of any Health Board adjacent to England.
However, will he tell us why? What makes that a logical assumption for the purposes of the measure?
In my view, the truly relevant distinctions would be geographically defined far more tightly than simply according to the administrative boundaries of health authorities. The Minister must accept that there might be people living in parts of Northumbria, Cumbria and the Scottish border areas who have no need of the provisions set out in the new clause but who may, none the less, derive benefit from them.

Mr. Denham: The reason that those health authorities and health boards are covered is that they encompass practices in which people are registered on both sides of the border. Therefore, those are the sensible health authorities and boards to draw into the legislation.

Mr. Brady: The Minister says that that is the reason for the inclusion of those health authority and boards, but the new clause does not limit the application of the procedures and situations set out in it to those people who are registered with practices which have patients on both sides of the border. In short, the Government are creating a potentially serious anomaly.
I am not familiar with the health authority boundaries, but as one who knows that part of the country reasonably well, I would hazard a guess that they encompass large geographical areas. Therefore, the Government are attempting to define in legislation extremely large areas to which the provisions will be applicable, even where there is no real need for those provisions or where the real need could be far more tightly defined, for example, by restricting the application of the provisions to those people who are registered with practices which have patients on both sides of the border. The new clause is badly drafted and it gives the legislation extremely wide scope.

Mr. Bercow: The Minister's intervention was interesting. Does my hon. Friend agree that, if the Minister is to offer a convincing rebuttal of my hon. Friend's case, it is necessary for him to show that, in the areas concerned, every practice, without exception, has patients registered on both sides of the border? If the Minister does not take this opportunity to rise and say that, my hon. Friend's case will rest.

Mr. Brady: I do not expect the Minister to leap to his feet, because he knows full well that he cannot demonstrate that that is so, and that is precisely what makes my point.
For the vast majority—probably 99 per cent.—of the residents in the health authority areas which will be affected by the new clause, the provisions are not a necessity. However, the new clause will change the nature of the health care provision that is available to them, and it will do so in a way that distorts the planning and provision of health care in a stretch of land along either side of the border between England and Scotland that is remarkably broad. That part of the country is, in the main, rural, so the health authority and health board areas are relatively large.
The new clause, in effect, blurs the border between England and Scotland for certain purposes. For the administrative basis of health care provision, the border could, in principle, be blurred away from the geographical border to the administrative border of the health authority or health board adjacent to the geographical border. As for the reason why the Government are trying to do that, I can only suggest that it is a conscious attempt to fudge some of the difficult problems raised by the progress toward devolved government in Scotland, for example, the inequities between England and Scotland in tax and spending arrangements that might arise from devolution. It is a cause of great concern. Many people in England and Wales are beginning to question the constitutional balance created by devolution. English voters are becoming increasingly concerned about the Barnett formula and the fact that their taxes will be used disproportionately to fund services in Scotland. The new clause will add to that effect.
For example, the Scottish Parliament might vote to increase taxation—by introducing the tartan tax that was debated at length during consideration of the devolution legislation—in order to provide better health services. However, that tax increase would cease to be acceptable to the Scottish people in the context of the new clause, which would cause those who are not the sole beneficiaries of that expenditure to provide the additional revenue.
The relationship between taxation and the democratic accountability for raising and spending it is ludicrously complicated. The Barnett formula and the existing anomalies in expenditure levels in England and in Scotland have been accepted—if only as a result of the passage of time. However, an additional complication could arise. Scottish electors could be asked to support the decision of the Scottish Parliament to raise taxation for the express purpose of augmenting health provisions on the northern side of the border. However, new clause 18 could lead to Scottish electors being taxed in order to spend more money not just on people south of the border, but on a relatively small and arbitrarily fixed group of them.
It is not appropriate to legislate to create an absurd anomaly. A small number of people may derive a disproportionate benefit for which others have paid and for which their elected politicians are not accountable. That could cause grave concern and a good deal of controversy. Our concerns would be lessened if the Minister would respond to the suggestion by my hon. Friend the Member for Buckingham (Mr. Bercow) and define the areas precisely. If he would come to the Dispatch Box and tell us that the new clause will affect only 50 or 100 people living in the most remote rural

areas of Cumbria, Northumbria and the Scottish Borders, we might be prepared to say that its constitutional abhorrence pales into insignificance.

Mr. Hammond: Does my hon. Friend agree that, in order to provide such an assurance, the Minister would have to contemplate freezing the lists of GPs in those border areas? Given the relative paucity of choice available to people living in those sparsely populated areas, would my hon. Friend not find that an unacceptable restriction?

Mr. Brady: I think I probably would—I certainly think that those affected would. Difficulties may arise if the lists are not frozen and this legislation is passed. Rather than registering with local practitioners, people who live outside the areas directly affected that would normally be served by border practices—they could live 20, 30 or 40 miles from the border—might find it advantageous to register with GPs close to the border in order to benefit from higher levels of expenditure. In very rural areas, people's local practice may conceivably be 10 miles south of them.

Mr. Hammond: My hon. Friend is absolutely right, but the issue is not simply the higher level of expenditure in general, but the availability in one area of a drug or treatment that is not available in another area. We have all heard stories of people selling up and moving house to get into a local health authority area where, for example, beta interferon is available. That could well happen across the border.

Mr. Brady: I absolutely agree with my hon. Friend. I would go further and say that not only is a clear incentive created for people to move house or register with a different GP—they might go to considerable lengths to benefit from treatment that they would otherwise be denied—but, giving due credit to health authorities and boards for their wit and intelligence in seeking to serve the interests of their population, it may be entirely appropriate for them to take into account their privileged status under new clause 18.
As designated health boards or authorities, part of their planning process may be to accept that they are part of a jigsaw that fits with the board or authority on the other side of the border. It would be perfectly possible under new clause 18 for a health authority or board deliberately to refuse a particular treatment in the knowledge that the corresponding board or authority on the other side of the English-Scottish border provided that treatment and that its own residents would not be disadvantaged by the decision.
Indeed, in aggregate, residents may benefit from such decisions because the Bill allows residents to have an à la carte health service in which they can pick a treatment that is available in their local health authority area and turn across the border to Scotland for a treatment that is not available where they live. Treatments such as beta interferon or erythropoetin, which was the treatment in question for the constituent to whom I referred earlier, may be available in one health authority area but not in another. That may become a permanent state of affairs


and may encourage co-ordination, whether formal or informal, in the provision of health services across the English-Scottish border.

Mr. Hammond: Managed from Brussels.

Mr. Brady: I am not sure whether my hon. Friend wants me to repeat his remark, but he said that it will be managed from Brussels, which is doubtless in the mind of the Government, although they may now think twice about their headlong rush towards integration, following yesterday's election results.
The result of new clause 18, however, for people who live in the border regions may be beneficial in that their health authority can co-ordinate treatment with the health board on the opposite side of the border. That would increase the number of treatments available to residents in that area, without any increase in total expenditure.
The disadvantage is to those people who live on the Scottish side of the border in the next tier of health board areas, but far more so to those people living in the next tier of health authority areas on the English side of the border because they are multiply disadvantaged by the Bill. They are already disadvantaged by having to pay taxes that disproportionately fund health services in Scotland under the Barnett formula.
Health authorities, with which we all deal, must make choices and decisions in conducting their daily business. They must make difficult decisions on how to divide the resources made available to them—whether the prescription of beta interferon is the best way in which to improve overall health in the area or whether money could be better spent on other treatment. Health authorities adjacent to the border would make fewer such choices under new clause 18.

Mr. Bercow: I am sorry to agitate and interrupt the eloquence of my hon. Friend's flow, but the scope for the form of administrative table tennis which he has described is perverse in the extreme. On the strength of his listening to Ministers' statements, does he judge that they are guilty of knavery or of folly? In other words, is this a Machiavellian plot or has the Minister, whom we know to be capable of this, stumbled into the mess inadvertently?

Mr. Brady: I thank my hon. Friend for that elegant intervention. I do not know whether the Minister has stumbled into this or whether his right hon. Friend the Secretary of State, who is perhaps even more capable of stumbling into problems, is responsible for it. My suspicion is that the proposed legislation is simply ill thought out.
The reason why the new clause has been tabled at this point is far from that in the picture painted earlier for my hon. Friend the Member for Lichfield: that there has been a crying need for such a provision for a long time and that it was absolutely necessary that the Government should now deal with something that has been causing difficulty. In fact, there had been no previous difficulty of any significance. Somebody suddenly realised that there might be one and thought that something ought to be drafted that might deal with it, subject to the approval of a suitable Order in Council by not only both Houses of

the Westminster Parliament but the Scottish Parliament. Perhaps I am more generous of nature than my hon. Friend the Member for Buckingham; I hesitate to attribute unkind motives to the Minister or suggest that he is making a foolish mistake.
The new clause appears to have been given minimal thought or consideration. It has been tabled on Report, instead of in Committee, where we might have had a much better opportunity to debate its implications. Had it appeared in the Bill in the first place, perhaps some of the very serious complications surrounding it could have been addressed earlier.
I suspect that there is no deliberate intention to deceive, although it may be convenient for the Government—if possible—to blur the inequities that arise from devolution, which are most obvious to those who live adjacent to the border. Those living nearer the border can see such inequities and problems in sharp contrast, whether in taxation, health care provision or other public services. Although I am far from convinced that the Government have made a deliberate attempt to blur such distinctions, my hon. Friend the Member for Buckingham was right to suggest that there is a possibility of knavery—and we should consider that.
Regardless of Ministers' motivation in tabling the new clause, this is an ill-judged piece of legislation. As has happened so many times in the relatively brief time that we have suffered the new Government's control of policy, legislation is being introduced which, as my hon. Friend the Member for Lichfield said, gives the Secretary of State very broad powers to introduce more detailed provisions without the facility for debate and amendment that there would have been, had they been included in the Bill.
That is unfortunate for Members of the House who, rightly, wish to debate these matters properly and in detail. Moreover, if the Labour Government are going to start paying attention to the concerns that the public plainly have about them, as demonstrated in the recent European election, they should address people's concern that the Government still behave in a way that sometimes consciously stifles debate. They are also concerned that, at other times, as in this instance, an over-reliance on delegated powers denies the Government the opportunity—they should start to understand that it is an opportunity—to enjoy the benefit of scrutiny in the House before they embody detailed matters in law.
If a tenth of the concerns that I and my hon. Friends have expressed about the new clause were to prove well-founded, the clause would constitute a bad piece of legislation. Those concerns will come back to haunt the Government, and Ministers will regret not acting on them. If they had had the good sense to put the detail of such material in the Bill, they would have benefited from hearing it debated, and from having the pitfalls highlighted.

Mr. Hammond: My hon. Friend is making an extremely powerful point. He was not privileged to serve on the Standing Committee that considered the Bill, but he might like to know that the Government tabled a new clause at the end of that Committee's consideration and have been forced to come back today with a substantial number of amendments to it. That demonstrates the truth of my hon. Friend's case.

Mr. Brady: I thank my hon. Friend. It is ludicrous to table the new clause in its current form yet still to fail


to address the concerns that are being expressed today. These matters should be the stuff of the primary legislation before us. It is not enough for a slice of the United Kingdom—I suspect, merely 100 miles wide at one point—on either side of the border between England and Scotland to be covered by a catch-all provision in the Bill, which can be defined only by subsequent delegated legislation.
The Minister, in his brief opening remarks, gave no information regarding the numbers of people who are resident in the areas of the health authorities and health boards that we are discussing. He gave us no idea of the geographical size of those areas. He gave us no idea of how many GP practices would be affected, either by the new clause or by the order that he presumably has in mind, but to which the House is not yet privy. He gave us no idea of the current disparity in terms of health expenditure on one side of the border or the other, or, in terms of weighted capitation, of the effect of that on different health authorities on either side of the border. He gave no indication of the kind of treatments that may currently be available in a health authority on one side of the border but which are not available in a health board area on the other side or, more likely, vice versa.
The Minister has given the House none of that information. I live in hope that he may put that right later, when he responds to this short debate. He flicks casually through his notes, but I am not certain that he has that volume of information in his possession as he sits in the House this evening.

Mr. Bercow: My hon. Friend's patience is renowned throughout the House, but I must trouble him once more. Does he agree that it is not necessary to gaze into the crystal ball when we can read the book? Does he accept that his point has not only intellectual merit, but practical validity? It is not just a theoretical concept that by fleshing out Government proposals in the Bill, we maximise the chance of better legislation and better service to the public. That is manifestly proven in the context of legislation that the Government have introduced in other areas of public policy. Does my hon. Friend agree that it is precisely because of the tendency to legislate by Order in Council and regulation that is not subject to the scrutiny of the House that the right hon. Member for Hartlepool (Mr. Mandelson), for example, got into such an unholy mess in relation to the working time regulations? Can we not learn from that experience?

Mr. Brady: I endorse everything that my hon. Friend said, but I am aware, Mr. Deputy Speaker, that you may not wish me to venture into other areas of policy. Assuming that having sold one house, the right hon. Member for Hartlepool (Mr. Mandelson) does not take advantage of the provisions of the new clause to buy another property in a health authority area where he may benefit from treatment on the other side of the Scottish border, I am not sure that I would be permitted to stray into that area.
The point is sound. Not only should the Government, as a matter of principle, bring these issues in detail to the House of Commons, but their own ends would ultimately be served better if they did so.
I suspect that the Minister does not have the basic, essential information that ought to be available to hon. Members now to enable them to reach a proper conclusion

about the impact of new clause 18. We have heard nothing about the number of people likely to be affected, the sums of money available, the sums spent and the treatments available in different areas. None of that information has been given to us, so the House is left in the dark.
Once again, we must agree a new clause that has wide parameters and about which we have virtually no information. That is profoundly wrong as a way of legislating and it will cause the Government considerable regret later.
The hon. Gentleman whose constituency I do not know and who was earlier described as the hon. Gentleman on the fourth Bench, but whom I know to be an hon. Member of great distinction, spoke about different levels of social deprivation in different parts of the United Kingdom. That is relevant. I expect that few hon. Members, if any, would disagree with the notion that there should be some degree of weighting in public expenditure on the basis of need, as the hon. Gentleman said.
However, new clause 18 provides a mechanism for the weighting of provision not on the basis of need, but purely on the basis of geography. It must surely be wrong that someone who lives in a wealthy part of Northumberland, close to the Scottish border, may derive much greater benefit from the measure than someone who lives in the most impoverished part of Newcastle upon Tyne would gain. My knowledge of geography is not quite so good on the Scottish side of the border. However, someone who lives in one of the remote border areas—for example, the Cheviots or wherever—may gain benefits regardless of economic status, the level of need and health indicators, putting him in a preferential position relative to those living in the most deprived parts of Glasgow or of other Scottish cities.
This is not about the provision of health care on the basis of need. It is not justifiable on any rational or moral ground. It is an attempt to gloss over an administrative problem that the Government created, but without giving proper thought and attention to the implications that it could have. The Minister's opening remarks gave me no confidence that the Government have thought things through to a position where they will be able to answer the difficulties when they bring forward their Order in Council.
I raise the question, in conclusion—

Mr. Bercow: Surely not.

Mr. Brady: I am saving myself.
Is it appropriate for the House to agree to accept a new clause that has massively broad parameters when we have been given no detail about the implications and about the people who will be affected by it? We have been given the assurance that these matters will be dealt with when the Government see fit to bring forward delegated legislation. Of course, there will be no opportunity to amend it. As it will have to be approved by both Houses of Parliament as well as the Scottish Parliament, that must leave open the possibility that the supposedly pressing need, according to the Minister, to tidy up administrative problems that have existed for some time, might be rejected and that the Order in Council might be thrown out not by this place, not by the other place, but by the Scottish Parliament.
If the Members of the Scottish Parliament are to do their jobs properly and are to consider the impact of legislation that carries the potential effect of requiring their constituents to pay for health provision for people living outside their constituencies and outside the boundaries of Scotland, they may see that there will be no benefit for the Scots and that health care resources may be diverted from Scottish people to English people. As an English Member, I may think that that is a reasonable state of affairs and may even up the current discrepancies in health expenditure on either side of the border. However, Members of the Scottish Parliament may see the matter in a different light.
Surely the questions that are being raised by myself and others must weigh heavily on the minds of Members of the Scottish Parliament. They will be dealing with proposals that can carry a huge disbenefit to some residents in Scotland. None of these matters has been dealt with by the Minister. I hope that he will attend to some of them when he replies. I hope that in my brief remarks I have highlighted that the Government have brought forward ill-considered and ill-thought-out legislation with potentially serious consequences, and have not bothered to bring the information to the House on which we can make a reasoned judgment.

Mr. Desmond Swayne: I propose to be brief. I did not intend to speak on the new clause, but I was tempted to do so by my hon. Friends the Members for Altrincham and Sale, West (Mr. Brady) and for Lichfield (Mr. Fabricant). A possibility has occurred to me that is rather different in scope from the possibilities that my hon. Friends have outlined. I should preface my remarks by saying that I have had some difficulty in understanding the clause although I have read it several times. It is not exactly transparent, perhaps because so little of its substance is present on the amendment paper. It seems that that will be manufactured in the form of an Order in Council somewhat later.
The thrust of the remarks of my hon. Friend the Member for Lichfield was that there would be a movement of patients from the English side of the border, seeking treatments on the Scottish side, because of the 20 per cent. better funding arrangements that are available to Scottish health authorities. I am indebted to my hon. Friend the Member for Altrincham and Sale, West for dwelling on the fact that the border becomes confused—he used the word "blurred"—as a result of the new clause.
My view is that the border will become a much more critical divide than hitherto in health affairs. That is because the Scottish Parliament will have absolute discretion when it comes to the treatments that it funds or does not fund. I shall put a specific possibility to the Minister and ask him to address it when he replies.
There is little doubt that the Scottish Parliament will develop its own identity both with respect to its attitude to health care and its attitude to moral issues. It strikes me that there is a distinct possibility of the flow of patients being entirely the other way round—people who are in the care of health authorities north of the border in the border areas seeking treatments south of the border. There is a real possibility that patients might legitimately

expect treatment under, for example, the provisions of the Human Fertilisation and Embryology Act 1990, which remains a reserved matter, while the Scottish Parliament decides as a matter of principle that it will not fund that treatment. There is the possibility that patients who are unable to secure treatment in Scotland will seek to use the provisions of the clause to secure that treatment in England. I have chosen the Human Fertilisation and Embryology Act, but I could have referred instead to the provisions of the Abortion Act 1967.
As I have said, the Scottish Parliament will have absolute discretion as to what procedures it is prepared to fund north of the border. It will be entirely operationally possible for that Parliament to deny a series of treatments in its funding decisions which, in terms of reserved legislation, the British people as a whole have been led to expect they may legitimately receive. There is a strong possibility in the years ahead of health refugees, as it were, coming to the border areas and seeking to use the provisions of the clause to obtain treatments which are not available in Scotland from English health authorities. I ask the Minister to address that possibility.

Mr. David Amess: I apologise to the Minister for not being here at the start of the debate; I was in my room, because I had anticipated that the statement on Kosovo would last an hour, although I think that it finished after only 40 minutes. However, I was watching his performance carefully on the monitor and I have to say to him that the start of proceedings on Report has been, in every sense, a hangover from his style in Committee. He came to the Dispatch Box and gently introduced new clause 18 as though it were harmless, but it certainly is not an innocuous measure.
6 pm
Today, a member of Her Majesty's Cabinet has talked about a low turnout and, according to that right hon. Member, a low turnout indicates that the majority of people are happy. There is a relatively low turnout in the Chamber at the moment, so I assume that the majority of Members are happy with the Bill and the new clause—but I am not at all happy with new clause 18 and I would not trust the Government an inch.

Mr. Hammond: Does my hon. Friend agree that the other possible interpretation of low turnout is bewilderment and the impenetrability of what one is dealing with? That would apply equally to the European elections and to the Bill.

Mr. Amess: My hon. Friend is entirely right and what he has said will perhaps seem even more true when I have developed my arguments about border arrangements.
I say to the Minister that accepting the new clause without query is not what the House is about. The Health Bill is on Report, which is an important stage of our consideration, and I congratulate my hon. Friend the Member for Altrincham and Sale, West (Mr. Brady), who taught the House how to be succinct and got a point over so that we understood it extremely well. Of course his constituents are angry about these border


arrangements. I understand, although he will correct me if I am wrong, that the general hospital in his constituency has closed two wards and moved 100 nurses to other—

Mr. Deputy Speaker: Order. Will the hon. Gentleman please return to discussing the border arrangements?

Mr. Amess: Of course, Mr. Deputy Speaker, but I congratulate my hon. Friend the Member for Altrincham and Sale, West on feeling so moved as to talk about the new clause in the way that he did.

Mr. Brady: Staying entirely in order, I should say that the planned closure of two wards at Altrincham general hospital—

Mr. Deputy Speaker: Order. That is not in order.

Mr. Amess: New clause 18 has five subsections, and I want to deal first with subsection (5), which says:
'English border area' means the area of any Health Authority adjacent to Scotland,
'Scottish border area' means the area of any Health Board adjacent to England.
I apologise if I missed the Minister giving the details of those health authorities in my rush to get to the Chamber from No. 1 Parliament street, but for goodness' sake, the Bill is a shambles. That was what we found all along in Committee and we have been provided with no proper detail.
The Bill was introduced in the House of Lords and has been in Committee, but still the Government have not got their act together. I do not know how many health authorities are involved, but would it not have been sensible for the Minister to tell us precisely which ones we are talking about?

Mr. Fabricant: I apologise for having had to leave the Chamber for a few minutes. My hon. Friend might like to know that when I asked the Minister for a definition, he simply referred me to another provision. He could not—perhaps he was unable to—name the health authorities concerned, and I find that shocking.

Mr. Amess: My hon. Friend is right. I recall forecasting in Committee that the Government would collapse, and I have been proved right—it happened yesterday, when their incompetence was well and truly shown up in those shocking results. I do not know why we are rushing through proceedings—we are here to scrutinise Bills properly—and I challenge the Minister to describe in detail when he responds to this brief debate which health authorities he is talking about.
This is an important matter because my constituents in Southend, West want it to be dealt with properly and want the Government to deal with it evenhandedly. If I knew the details of the individual health authorities, I might be in a strong position to bring out particular points in respect of the border arrangements. I speak only for myself, but I find the whole concept of borders offensive. By using such a style in the Bill and in the new clause, the Government are setting people against people. What is going on is outrageous.

Mr. Bercow: Does my hon. Friend agree that we need to know a number of things from the Minister? First, does


he yet know exactly which authorities he has in mind? Secondly, has he informed the Members whose constituencies fall within the areas of those authorities? Thirdly—my hon. Friend will agree that this point is manifestly related to the matter we are discussing—should we not be told whether those Members are in the Chamber, as they are interested parties? If not, why not?

Mr. Amess: My hon. Friend is on to the precise point, but if he had been privileged to serve on the Standing Committee he would have witnessed at first hand what a shambles the Bill is. Although I hope that I will be corrected, I suspect that we will not find out which health authorities will be affected. That will happen when the Bill goes to the other place, because the Government hope that it will not want to scrutinise the Bill properly; but I know that the other place will certainly scrutinise the Bill properly.
One of the Labour Members who has spoken—I am determined to tease out which constituency he represents—was an outstanding Minister who had the guts to resign over child benefit, I believe, or a similar measure. As he responded to a point made by one of my colleagues, he said that Scotland needs more money to be spent on health care and then talked about areas of deprivation. Since this rotten Government came to office on 1 May 1997, there have been areas of deprivation across the length and breadth of the country. Southend, West is now an area of deprivation.
I am delighted that the Conservatives got half the votes cast in my constituency in the European election.

Mr. Bercow: I am interested in what my hon. Friend has to say, but I simply cannot abide any longer the House sitting on the border, languishing between knowledge and ignorance. I therefore hope that he is grateful to me for pointing out that, unless I am much mistaken, the hon. Gentleman in question represents Edinburgh, North and Leith. He has been extremely modest in refusing to take a bow, but I do not want him skulking in the shadows unnamed.

Mr. Amess: My hon. Friend will have helped other people, who report on these matters, and I thank him for his advice.

Mr. Fabricant: On that point about skulking, has my hon. Friend noticed that only at this late stage has the Scottish Health Minister arrived for the debate? We have been discussing the border areas of Scotland and England; while England has been represented, Scotland, as ever, has been unrepresented.

Mr. Amess: My hon. Friend is on to an excellent point.

Miss Widdecombe: Where is the Secretary of State?

Mr. Amess: Indeed, where is the Secretary of State?

Miss Widdecombe: My hon. Friend will be pleased to know that we have had a response to that question—the Minister assures me that the Secretary of State has much better things to do with his time.

Mr. Amess: Well, there we are. Obviously, Her Majesty's Government have learned nothing from what happened on Thursday and the count that took place on Sunday. Their arrogance is beyond belief.
I shall gently chide my right hon. Friend. Earlier, I referred to turnouts. The turnout in the Chamber is beginning to improve, so it seems that more and more hon. Members, certainly on the Conservative Benches, think that the border arrangements in new clause 18 are important.

Miss Widdecombe: Can my hon. Friend judge the importance attributed to border arrangements in the eyes of the Government by the number of Labour Members who have spoken?

Mr. Deputy Speaker: Order. Perhaps we could now turn specifically to the border arrangements.

Mr. Amess: I was referring to social deprivation. The NHS figures show that in 1998–99, £36,860 million was spent in England compared with £4,642 million in Scotland. For 2001–02, the figures are £45,370 million in England and £5,549 million in Scotland. In 1998–99, the figure per head was £746 in England compared with £907 in Scotland, and for 2001–02 it is £910 in England and £1,087 in Scotland. The Minister owes it to the House to give a thorough answer to the question about the real reason for the disparity in spending.
The Minister's hon. Friend, the hon. Member for Edinburgh, North and Leith (Mr. Chisholm), referred to these matters. I remember serving on a Standing Committee of a health Bill some years ago, when we debated the amount of money being spent in Scotland. Before hon. Members shout me down, I should like to refer to a debate on Scottish teeth. It was clear that in spite of the huge amount of money being spent on dental care in Scotland, Scottish teeth needed a great many more fillings than English teeth. During the Committee stage of that Bill, Labour Members, who were in opposition at that time—it is a pity they are not now—argued that that was due to diet and social deprivation. That is utter nonsense. My constituents' teeth are every bit as important as the teeth of the people affected by these border arrangements.

Mr. Deputy Speaker: Order. I remind the hon. Gentleman, I hope for the last time, that this debate is not about relative spending on health north and south of the border. It is specifically about technical arrangements on the border.

Mr. Amess: I want to draw the Minister's attention to the heart of new clause 18. He told us that subsection (4) applies to any functions under the National Health Service (Scotland) Act 1978 or part I of the National Health Service (Primary Care) Act 1997, which are exercisable by the Scottish Ministers or any health board or NHS trust established under the 1978 Act. I may have missed the Minister giving any detail about the 1978 Act and the matters that would be affected, but I would ask him to spell out in precise detail, when he replies to the debate, what he was referring to.

Mr. Fabricant: Does my hon. Friend agree with me that the questions he asks are a consequence of the fact that the new clause has been introduced so late? If it had not been tabled late, he would have been able to use the excellent explanatory notes, which have been prepared by able officials in the Department of Health.

Mr. Amess: I have not had time to read the explanatory notes. They may be excellent, but I suspect that they do not explain the 1978 Act in detail. Perhaps the Minister will tell us whether they deal with the 1978 Act.

Mr. Brady: Before my hon. Friend departs from subsection (4), will he tell us whether it is his understanding—as it is mine—that the phrase "Scottish Ministers" applies to Scottish Ministers in the House rather than to members of the Scottish Executive? Should any of the health matters dealt with by the Scottish Executive also be covered by subsection (4)?

Mr. Amess: My hon. Friend leads me on to another subject: the powers of the Scottish Parliament in relation to the Bill. In Committee, members of Her Majesty's loyal Opposition were somewhat confused about why on earth the Bill was being introduced when it was clear that the Scottish Parliament would take over the matters that we were dealing with. I have tried to follow the Bill carefully, but I am still not convinced about the relationship between the powers and duties under the Bill and the powers of the Scottish Parliament. If the Minister is saying that the border arrangements in new clause 18 override anything discussed in the Scottish Parliament, what on earth is the good of the Scottish Parliament? The Scottish people have been sold a pig in a poke.

Miss Widdecombe: A pup.

Mr. Amess: A pup, or whatever it is. They have been led up the garden path. I am pretty sure that the good citizens of Scotland will be interested to know that the Parliament they voted for in the referendum will not be as important as they believed it would be at the time, because subsection (4) will reduce the power that they thought it would have.

Mr. Fabricant: Does my hon. Friend recall that the part of the Bill beginning with clause 45, where new clause 18, if it is passed, will be inserted, provides that powers of the Scottish Parliament can be overridden by the Bill? Does that not make a mockery of devolution? Is that not one in the eye for Scottish electors who thought they were electing a Labour Government to get Scottish devolution only to discover that—rightly in my opinion—the Westminster Parliament can overrule the Scottish Parliament?

Mr. Amess: My hon. Friend's remarks are valid in relation to border arrangements.
Subsection (2) states:
This subsection applies to any functions under the 1977 Act, or Part I of the National Health Service (Primary Care) Act 1997".
As a courtesy to the House, the Minister should have given us a little explanation of the 1977 Act. He may want to intervene or to deal with the matter when he winds up the debate.
I was sent here as a Member of Parliament, supporting my party's beliefs, to represent the interests of my constituents. I genuinely believe that when we complete the Report stage of the Bill tomorrow—[Interruption.]—sorry, next week. When we eventually complete the


Report stage, my constituents will be very angry about new clause 18. They will not be happy about the cross-border arrangements.
The Bill will be a charter for private medicine. My hon. Friends the Members for Altrincham and Sale, West and for Runnymede and Weybridge (Mr. Hammond) talked about people moving across the border. The situation is a little like the council tax. We all have a road in our constituency where people on one side pay one charge and those on the other side pay a different charge. Usually the charge is lower for a Conservative council and higher for a Lib-Lab council. The disparities caused by the new clause will be similar.
The Minister fought the general election on a manifesto that said "Vote Labour on 1 May and you will save the national health service." Bearing in mind the new clause, the manifesto should have said, "Vote Labour on 1 May and you will end up needing to save the national health service." The Bill is a shambles. Why did the Minister not mention in Committee that he was going to introduce cross-border arrangements? The Government were talking about the Bill last year, but still, on 14 June 1999, they have not got their act together.

Mr. Bercow: The Minister is an agreeable fellow, but I know from experience that he is adept at avoiding questions. He dances round the issue, rather like Muhammad Ali used to dance like a butterfly round the boxing ring. Will my hon. Friend take this opportunity to request that the Minister answer the specific points that were raised earlier? Which authorities does the Minister have in mind? Has he spoken to hon. Members who are directly affected? On what day did he decide to introduce the new clause? We must have specific answers to those specific questions tonight.

Mr. Amess: I hope that we get answers to those points. We kept putting points in Committee, but we were short-changed. We may well be short-changed on Report as well.

Mr. Hammond: I remind my hon. Friend that I said earlier that the Minister wrote to our right hon. Friend the Member for Maidstone and The Weald (Miss Widdecombe) during the Committee stage about his intention to introduce a new clause along these lines. A more fruitful line of inquiry might be why the issue was so complicated that the Government were not able to include provisions for due consideration in Committee and why we had sight of the new clause only last week.

Mr. Amess: My hon. Friend tempts me to get involved in a very long discussion that may be ruled out of order.
The Government will regret the day they introduced this disgraceful Bill, which has been delivered incompetently. I do not know who is to blame, but I think that it might be the person in charge of the Government. My hon. Friend the Member for Runnymede and Weybridge was right to say that the new clause could have been introduced earlier. He said that he saw the details last week. I had a busy week campaigning, which was my main priority. I did not have time to study the new clause in detail. I have had to mug up in the brief time that

I have had today, and I am not best pleased about that. I have had to dump all my other important arrangements to try to understand the new clause.

Mr. Deputy Speaker: Order. The timing of the tabling of the new clause has been more than adequately dealt with. Perhaps the hon. Gentleman will deal with its content.

Mr. Amess: The fifth point about the cross-border arrangements on which I want a direct answer from the Minister relates to an article that I saw in The Independent entitled "Pupils to Train as Mini-Paramedics", which said that Scottish schoolchildren were being trained in resuscitation techniques as part of a campaign to reduce the number of deaths caused by heart attacks. I applaud that. I went to a St. John Ambulance reception at which we were shown how to resuscitate people, although I would not willingly and enthusiastically jump to give resuscitation to—no, on second thoughts I would of course want to revive anyone. The article says that the campaign, funded by the British Heart Foundation, will train children in how to keep a heart attack victim alive while they wait for an ambulance to arrive. I understand that similar projects have been undertaken in America.
Will the programme be affected by the cross-border arrangements? That may be covered in subsection (1), but if it is I did not understand it and I heard nothing about it in the Minister's speech. I suspect that it might be affected. A great deal of trouble has been taken over the scheme—possibly unnecessarily.
Surely to goodness the new clause is an admission that the Government were wrong about fundholding and that it is after all a good idea. The new clause will encourage people to cross borders. I assume that the hon. Member for Dartford (Dr. Stoate) has been told to leave the Chamber. He was not welcome in Committee, either. Having tried to intervene here and have a decent debate, he has gone off. He wanted to say something about fundholding. The new clause and the Government's policy of setting citizen against citizen are an admission that they got it wrong about fundholding. Under fundholding, doctors could ring round and find out who was available to perform an operation more quickly. That was a good thing.

Mr. Bercow: I am listening intently to my hon. Friend. Will he entertain the possibility that the hon. Member for Dartford (Dr. Stoate) was excluded from membership of the Standing Committee not because of his views on fundholding arrangements or cross-border provisions—

Mr. Deputy Speaker: Order. That has nothing to do with the new clause.

Mr. Amess: It was kind of my hon. Friend to intervene, but I must concentrate on cross-border arrangements. I have heard a sedentary comment from a Labour Member about queue-jumping. My goodness, given the Government's policy it is appalling for any Labour Member to talk about queue-jumping. However, we will not get to that debate for some time.
6.30 pm
When the Minister replies, I hope that he will give the House a little more detail about subsection (3) of new clause 18. [Interruption.] My right hon. Friend the Member for Maidstone and The Weald (Miss Widdecombe) suggests that the Minister has not looked at new clause 18. I hope that that is not the case, because we are on Report and Ministers should be so familiar with the detail of their legislation by this time that the answers should pour forth from them. Therefore, it is not unkind to expect the Minister to give the House more detail about subsection (3). It puzzled me. It states:
Her Majesty may by Order in Council provide for any functions to which subsection (4) applies which are specified in the Order, so far as exercisable in respect of the provision of services to persons in Scottish border areas".
I do not understand that and I want to know whether the Minister understands it. As the Member of Parliament for Southend, West I need to understand it because after this debate my constituents will want to know what it means.

Mr. Fabricant: Is it not apparent what the provision means in the sense that yet again it is an example of the Government not knowing what they intend so they give powers to the Secretary of State to make any decision he likes about doctors, patients, border areas, non-border areas, Scotland and England?

Mr. Amess: My hon. Friend may be right, but the new clause is defective. The Minister will claim that it is not and we will be asked to accept it, but when it goes to the House of Lords an amendment will be tabled to it. Subsection (3) continues:
to be exercisable (instead of any corresponding function to which subsection (2) applies)".
I do not know what subsection (2) is and I wonder whether the Minister knows what it is. It continues:
in respect of the provision of the services in question to persons in English border areas who are specified in the Order.

Mr. Bercow: Does my hon. Friend agree that the litmus test of whether the Minister understands the new clause is that when he replies to this short debate he is able to explain its rationale and content without reference to a crib sheet provided by those whom we are not supposed to name?

Mr. Amess: I do not know how I should comment on that, although I believe that the Minister was a barrister or a solicitor before he became a Member of Parliament. We will have to see whether he stands at the Dispatch Box without notes and can answer my point about subsection (3).
The Minister, when he worked on new clause 18, could have made it more easily understandable. The arrangements for borders will become a big issue. In fact, I shall suggest to the Chairman of the Health Committee that we ask the Minister to come and give evidence to the Committee to justify the border arrangements. The more I listen to myself talk, the more I believe that the new clause is unfair.

Mr. Fabricant: It is capricious and unfair, but is not it also worrying? Subsection (3) specifically states that the

Secretary of State may
by Order in Council provide for any functions".
Has my hon. Friend discovered any other clause in the Bill that is so open that the Secretary of State can provide for any function? Is not it outrageous that he will be given a blank cheque?

Mr. Amess: The whole flavour of proceedings in Committee was that the Opposition were unhappy with the wide-ranging powers given to the Secretary of State for Health. I do not wish to imply that we thought that the Secretary of State for Health was incompetent, but we thought that he was too busy to do justice to all those functions.

Mr. Fabricant: We are in no position to judge whether the Secretary of State is competent or incompetent because he did not do the Committee the courtesy of turning up for even five minutes.

Mr. Amess: My hon. Friend is right. As my right hon. Friend the Member for Maidstone and The Weald was present throughout in Committee, the Secretary of State's absence was unfortunate.

Mr. Hammond: To return to the point that my hon. Friend was making about the wide order-making powers that the Secretary of State will have, does he agree that the Minister could have saved much debate and given us much reassurance if he had made draft orders and regulations available to us? Does my hon. Friend recall that we pressed the Minister on whether they would be made available in time for the debate today? Sadly, we have not seen any.

Mr. Amess: My hon. Friend is right and I congratulate him on his diligence in Committee and today. As he knows, we were not afforded that courtesy. Indeed, we tried to make constructive, sensible changes to the Bill, but we did not have one amendment accepted.

Mr. Deputy Speaker (Mr. Michael J. Martin): Order. We are not considering what was accepted in Committee. We are dealing with the new clauses and amendments before us.

Mr. Amess: We would not be in the mess that we are now in—grappling with new clause 18—if the matter had been handled differently. The Minister is charming and persuasive and he thought that new clause 18 would be accepted without any debate. However, I do not trust the Government's motives in the border arrangements.
I wish to go into more detail about the health authorities adjacent to Scotland.

Mr. Swayne: Is it appropriate to call them authorities, given the huge and sweeping powers that the new clause will give the Minister over every aspect of their function? Are they authorities in any sense?

Mr. Amess: My hon. Friend makes a good point. I pointed out earlier that the Bill is defective and we will probably find that that description of authority is removed when the Bill is discussed in the House of Lords. The Minister has so far failed to give us any details of the


health authorities adjacent to Scotland. Many people are waiting to hear which health authorities have been affected. As my hon. Friend the Member for Runnymede and Weybridge pointed out earlier, people will wish to move to those areas because they think that they will get better health care. I thought that the Labour party was supposed to be about equality, but the new clause is all about inequality. It is divisive in every sense.

Mr. Bercow: I am still puzzled by the way in which the new clause was tabled at such short notice and without explanation. Having consulted the reference sources, I have discovered that among the Minister's interests are cooking and walking. We welcome the fact of that hinterland, but perhaps he imagines that tabling the new clause at this late stage, without explanation or apology, is like producing a new recipe. Is not it important that, wherever else he walks, he does not walk away from his responsibility to answer the serious challenges that we have posed to him?

Mr. Amess: That is a telling point. The Minister knows that if he gives us a precise list of the authorities concerned, Her Majesty's loyal Opposition may accept the argument. My constituents want to know which health authorities are to get special treatment.
The Labour Government talk about equality and the Minister disarmingly suggests that the new clause is merely a tidying-up measure. I believe that we have not been given the details because there is an argument going on behind the scenes. There is uproar in health authorities throughout the country, for all manner of reasons that we will discuss later. There is a row about which authorities are to be included, because inclusion will bring favourable treatment. My constituents think that that is unfair.
As the hon. Member for Edinburgh, North and Leith (Mr. Chisholm) said, there are areas of great social deprivation, not only in Scotland but throughout the country. The areas on the other side of the border will be very upset about the favourable treatment given to the authorities on the list.

Mr. Bercow: If the authorities due to benefit from the special arrangements have not yet been determined, is not it possible that, in the argument that is raging behind the scenes, Ministers are planning to work on the basis of a conformists' charter, and that Labour Members who are prepared to suck up to the Government will benefit from the arrangements, while those who are not, such as the hon. Member for Edinburgh, North and Leith (Mr. Chisholm), who is a faithful servant of his constituents, will not? Must not these matters be disclosed to the House without delay? It is not acceptable for this hole-in-corner practice to be allowed to continue.

Mr. Amess: My hon. Friend is entirely right. The Government talk about being transparent. My goodness, they were found to be transparent on Thursday and when the votes were counted on Sunday.
Let me inform my hon. Friend that there is a row going on between the Scottish Parliament and the Government about which health authorities should get preferential

treatment. I suspect that the Lib-Lab alliance running the Scottish Parliament is falling out with the Government. If there were nothing underhand—

Mr. Deputy Speaker: Order. The hon. Gentleman should not be addressing the hon. Member for Buckingham (Mr. Bercow); he should be addressing the Chair.

Mr. Amess: I apologise, Mr. Deputy Speaker.
6.45 pm
There is something underhand going on. The Minister must surely realise that the listing of the health authorities is crucial to our accepting the new clause; we could not countenance accepting it otherwise.
All Members of Parliament and of the Scottish Parliament are batting for resources for their own areas, so they all want favourable treatment for their health authorities. My hon. Friend the Member for New Forest, West (Mr. Swayne) said that perhaps the word "authority" was no longer appropriate. He could be right. If the legislation had not been introduced in so shambolic a fashion, we would know what responsibility Health Ministers in the Scottish Parliament have for health authorities and the relationship between that responsibility and legislation going through our Parliament.
The second part of subsection (5) is of equal importance and is perhaps a point on which all Scottish Members should seek to speak. If they do not speak, their constituents will want to know about it.

Mr. Brady: Is not that especially true given that this is one of the few areas of debate in which Scottish Members can rightly participate?

Mr. Amess: My hon. Friend has grasped the precise point. Here is an opportunity for the 72 Scottish Members—

Sir Robert Smith: On a point of order, Mr. Deputy Speaker. Will you clarify that it is in order for all Members of Parliament to speak on any matter that the House is discussing?

Mr. Deputy Speaker: Every hon. Member would know that. Hon. Members are making a debating point.

Mr. Amess: Thank you, Mr. Deputy Speaker. I could comment on that point of order, but I had better not.
Every Scottish Member should note the second part of subsection (5). Sadly, we have no Conservative Members of Parliament in Scotland at the moment. [Interruption.] My hon. Friends remind me that we have two Members of the European Parliament there; or perhaps more. We have Scottish Euro-Members but no Scottish Members of Parliament. Labour, Liberal and Scottish National Members should surely to goodness want to know about the health boards adjacent to England.
If the point made by the hon. Member for Edinburgh, North and Leith about areas of social deprivation is valid, surely many Scottish Members should want the Minister to tell us which health boards are affected.

Mr. Chisholm: I want to put it on the record that I never mentioned areas of deprivation, but I have been


slightly shy of intervening because, after five weeks in the Scottish Parliament, I am in a state of culture shock: up there we are trying to have genuine debate and scrutiny rather than the time-wasting self-indulgence that we are witnessing today.

Mr. Deputy Speaker: Order. The hon. Member for Southend, West (Mr. Amess) is not time wasting. I would not allow that. However, he has made his case about the cross-border authorities, and must move on.

Mr. Amess: Thank you, Mr. Deputy Speaker, for not allowing me to respond to the point. In fact, I had not realised that the hon. Member for Edinburgh, North and Leith was also in the Scottish Parliament.

Mr. Bercow: I do not want to tempt my hon. Friend away from his normal path of rectitude, as he always adheres to the traditions of the House. However, the hon. Member for Edinburgh, North and Leith is the only Scottish Labour Back Bencher in the Chamber. Does not my hon. Friend agree that it is important that the Minister, when he winds up, says whether those hon. Members affected by the new clause have been briefed in advance? Are Labour Members absent because, as the relevant information has been vouchsafed to them already, they think that they need not contribute, or because they are incompetent and have simply forgotten that the Bill has come back on Report today?

Mr. Amess: The reason is arrogance: Labour Members think it a bore to scrutinise legislation. They accept without question everything that the Government propose. That is outrageous. This is the mother of Parliaments, and hon. Members should understand that they are not irrelevant to the scrutiny of legislation. I would not have spoken if the Minister had intervened to list the authorities and health boards affected, but he has not done so.
It is frustrating that Opposition Members get no answers to their questions. I find that I am able to challenge the Executive only in Select Committee. New clause 18 deals with important matters. It is all about money spent in the health service, but the disparity that it introduces is unacceptable. It is also unacceptable—and arrogant—of the Government to table a new clause and expect no one to question the detail. The National Health Service Act 1977 and the National Health Service (Primary Care) Act 1997 matter.

Mr. John Hayes: My hon. Friend makes a profound point, but this is not the first example of such behaviour by the Government. Introducing new clauses in this way has become the hallmark of this Administration. It is impossible to examine important measures in sufficient detail, and I am surprised that Labour Back Benchers—who are also entitled to hold the Executive to account—do not feel the same way. Although my hon. Friend is too generous and liberal with the Government, I support him and hope Labour Back Benchers will do the same.

Mr. Deputy Speaker: Order. I have no argument with the point being made by the hon. Member for Southend,

West, but he has made it several times. Once a point has been made, it cannot be repeated. The hon. Gentleman must move on.

Mr. Amess: The Minister owes it to the House to convince us that the new clause is in the best interests of all United Kingdom citizens. For myself, I found it profoundly unsatisfactory that the Minister moved the new clause without giving any detail of its affect on the rest of our constituents. The detailed arguments about people moving house and changing doctors are relevant, because the Government's health strategy reveals a profound misunderstanding of how health care should be delivered.
This is bad legislation. As I said earlier, I am suspicious of the Government's motives with the new clause, which will affect health care delivery in every part of the country.

Mr. Swayne: On the national question, I refer my hon. Friend to the brief intervention from the hon. Member for West Aberdeenshire and Kincardine (Sir R. Smith). My hon. Friend was very courteous in giving way, so short was the hon. Gentleman's appearance in the Chamber. Does my hon. Friend agree that some legislation, such as that covering human fertilisation, remains the prerogative of this House, but that determination of the provision in Scotland of treatment under that legislation is the sole preserve of the Scottish Parliament? That may place a differential burden on health authorities—

Mr. Deputy Speaker: Order. I invite the hon. Gentleman not to get into such matters.

Mr. Amess: I shall say to my hon. Friend only that it is a discourtesy when an hon. Member intervenes in a debate and then scuttles out of the Chamber.

Dr. Evan Harris: My hon. Friend the Member for West Aberdeenshire and Kincardine (Sir R. Smith) made a point of order, not an intervention.

Mr. Deputy Speaker: Order. I am not concerned about who enters and leaves the Chamber, as that has nothing to do with new clause 18. I am concerned with the debate, which is about the amendments before us.

Mr. Amess: I am worried that new clause 18 will have an adverse effect on health care throughout the country. It will be discriminatory, and will introduce a great disparity in health care provision between areas. People will find it very confusing.
I think that the Minister's heart has never been in the Bill. I do not doubt that he is doing his duty for the Government, but I doubt that he would table new clause 18 were he in overall charge of the Bill. I think that he agrees that it will cause great dissatisfaction among our constituents, and believe that he will regret the day that he came to be associated with the Bill and the new clause.
Although some hon. Members believe that a low attendance in the Chamber indicates satisfaction with a proposal, I feel so passionately about the Bill that it is important that we scrutinise it properly on Report. I shall not desist until I get some straight answers. I have asked


five specific questions of the Minister. If the Minister would, at the very least, provide a list of the health authorities and boards affected on either side of the border, he would restore my faith in his good will.
7 pm
I am dissatisfied with the way in which this legislation is being handled. People look to this Chamber to legislate in the best interests of everyone, and I hope that the Minister will realise that the disparity in treatment that will be caused by new clause 18 is not in the best interests of his own constituents, of my constituents or of the constituents of my hon. Friends the Members for Altrincham and Sale, West, for Buckingham (Mr. Bercow), for Uxbridge (Mr. Randall), for New Forest, West, for South Holland and The Deepings (Mr. Hayes), for Runnymede and Weybridge, for Rutland and Melton (Mr. Duncan), and for my right hon. Friend the Member for Maidstone and The Weald. The Minister should withdraw new clause 18 because he should admit that it has been defectively drafted. If he thinks that we will accept it without question or that it will not be properly scrutinised when it returns to the other place, he will be disappointed.
I appeal to the Government to give the House detail on the five points that I have raised and the other points made—so succinctly—by my hon. Friends.

Mr. Denham: I shall try to answer as many points as possible, but the hon. Gentleman will understand if I have sometimes missed his meaning during the past hour.
It is worth remembering what I said earlier. We estimate that about 3,500 patients will be affected by the Bill, which is the number of patients in England and Scotland who are registered with a GP practice on the other side of their border. I would not be introducing the new clause if I had not been assured that it had been fully explained to health authorities and boards and the other groups involved and that they had been fully consulted. Everyone who has responded has been in favour of our approach. The new clause addresses practical problems that have faced GPs who provide primary care in what are often scattered rural communities.

Mr. Brady: What about the health authorities or boards not immediately adjacent to the border? Were the next ones up consulted too?

Mr. Denham: I am fairly certain that they were not; I see no reason why they should have been. The health authorities and boards concerned are responsible for areas rather larger than those covered by the practices involved. I could see no point in extending consultation further south or north of the border. I had to be sure that the measure was supported. In fact, the idea was initially suggested not by the Government, but by general practitioners who have complained about the current position for several years.

Mr. Swayne: In what detail were the health authorities consulted? How the Government intend to proceed is not clear from the new clause. Presumably, the health authorities were given detail that we have been denied.

Mr. Denham: As I have already said, they were told that we intended to use the new clause to enable health

authorities, primary care groups, primary care trusts and the Scottish equivalents to commission services for all their patients, irrespective of on which side of any border they lived.
The hon. Member for Runnymede and Weybridge (Mr. Hammond) asked about part II services.

Mr. Bercow: Was the estimate that 3,500 people are likely to be affected based on current figures, which could increase or decrease? Alternatively, was it predicated on the assumption, to which my hon. Friend the Member for Altrincham and Sale, West (Mr. Brady) has referred, that lists would be frozen?

Mr. Denham: For 1998–99, the exact estimate was that 2,313 English residents were on lists of GPs in Scotland, while 1,125 Scottish residents had GPs in England.
Several hon. Members have asked about how orders would be made and which patients would be affected by them. Although it is highly unlikely that people will sign up for a practice many miles from their homes to gain some perceived benefit, I can assure the House that any order would be specific about the category of people to whom it would apply, which gives us the ability to tackle that unlikely scenario. I was asked whether orders could fix the number of patients at the time of their introduction. Order-making powers might enable us to prevent people from signing up for practices many miles from their homes where it would be unnecessary or perverse. However, we see no need to fix lists and have taken no such decision. New patients are always moving in and out of areas and registering with a GP practice.

Mr. Brady: Surely there must be many cases—beta interferon, for example, or any other expensive drug or treatment—in which it would be entirely rational for someone to move house into an area covered by an order. However an order is drafted, it cannot possibly preclude people who do that from being allowed to register with a GP.

Mr. Denham: The position has been misunderstood. If people felt now that it would be better to move either north or south of the border, they could do so. We must focus on the need to sort out the practical problems faced by GP practices and patients when it comes to the delivery of health care in border areas. The new clause is a sensible means of dealing with those problems.

Mr. Bercow: Will the Minister give way?

Mr. Denham: I have given way several times and would like to get on. We have had a lengthy debate and I want to move on to some of the other reasonable questions that were posed.

Mr. Hammond: I have listened carefully to the Minister. Without going to the extreme solution of moving house, will the hon. Gentleman clarify one matter? Where a health authority area includes a number of people who are patients of a GP over the border, would anything prevent any other persons residing in that authority area from signing on with that GP if they wished to do so, or can only certain people in the area access that privilege?

Mr. Denham: I may have missed the hon. Gentleman's point, but at the moment if a Scottish patient, for example,


registers with an English GP, that GP has to make provision under the Scottish health service and vice versa. New clause 18 seeks to deal with the problems that arise from that situation.
At present, if one crosses the border to register with a GP one none the less remains treated by one's own, English or Scottish, health service. That decision was taken during the early 1990s, I presume. That causes GPs or primary care groups practical problems, such as being able sensibly to commission treatment on behalf of their patients. That is why it is more sensible for treatment for all patients of the practice to be commissioned because they are attached to that practice rather than according to the health authority in whose geographical area they live.

Mr. Hammond: I thank the Minister for that explanation, which was extremely useful. However, he did not deal with my question. Is he telling the House that only people who live in a tightly defined sub-region of the health authority or health board area can access a GP on the other side of the border, or would I be right in thinking that any patient who lives in the area has the right to transfer? Would he not anticipate an exodus of patients to those border GPs, if there were sufficient incentive—for example, if there were significant differences in treatment and service availability on either side of the border?

Mr. Denham: I do not anticipate that trend developing in practice. One can construct such a theoretical argument—the hon. Member for Altrincham and Sale, West (Mr. Brady) did so—but in practice, most people, sensibly, want their GP to be within a reasonable distance. We are talking about vast rural areas. GPs can be a long way away and it is unlikely that people will want to go even further. Also, it is unlikely in practice that such a disparity in services will arise. Indeed, had real concern that that would happen existed, I am sure that it would have been mentioned by the people we directly consulted—the GPs themselves, who are concerned about their patients, and the health board in the area.
There are two further protections. The hon. Member for Runnymede and Weybridge asked whether anyone could theoretically sign up to a GP over the border. The order can specify the persons to whom it applies and the functions affected. Also, as I said—this answers the question about overruling the Scottish Parliament—each order will be subject to affirmative resolution both here and in the Scottish Parliament. Therefore, the provisions being made under the new clause could be scrutinised.

Mr. Bercow: Will the Minister give way?

Mr. Denham: One more time.

Mr. Bercow: I am grateful to the Minister, whose patience and charity are well established throughout the House. Will he explain whether the order could not only specify categories of people to whom the arrangements would apply, but limit the number to whom they would

apply? Does he accept that in either case a problem would arise? If there is a limit on numbers, it is arbitrary; if there is not, the flood gates have been opened.

Mr. Deputy Speaker: Order. That was not a very brief intervention.

Mr. Denham: I had quite settled back into my seat, Mr. Deputy Speaker.
The order could specify the number of people. I am not sure that that is likely to be the way in which one would approach the problem, but the hon. Gentleman asked a reasonable question about the breadth of the legal provision, and the answer is yes.
I must deal with two specific points. First, the hon. Member for Runnymede and Weybridge asked about the fact that part II arrangements are included in the drafting of the clause and about our intentions in that regard. That has been done to allow the scope, if it were decided that we should do so, for streamlining part II arrangements for cross-border GPs who—this is analogous to the commissioning of care for patients—work to two different Red Books for two different sets of patients. The drafting of the Bill would enable that to be streamlined, but I must stress for the record that we have not decided to go down that road and we have not even begun any consultation with the GPs, health authorities or health boards affected. We would certainly want to do so before moving in that direction. The extension to part II would allow that change to take place.

Mr. Hammond: I thank the Minister for that clarification. If he has made no moves in that direction and has not begun any consultation, what changed between the date of his letter to my right hon. Friend the Member for Maidstone and The Weald (Miss Widdecombe) the week before last and his tabling of the new clause last week?

Mr. Denham: The answer to that question is that the clause was tabled after further examination of the issue and the provision that we should make.
I have always regretted the introduction of new clauses at a late stage in a Bill, as I did when we were in opposition. During the passage of the National Health Service (Primary Care) Bill, which was considerably less lengthy and complex than this Bill, three times as many new clauses were introduced on Report than have been introduced for this Bill, which I thought regrettable. I recall Conservative Members making speeches from the Government Benches that deprecated the fact that so many new clauses were introduced—well, I would like to think that I can recall that, but I think that they overlooked the matter at the time.
The final and most important question concerns the funding arrangements. I do not intend to debate the entire Barnett formula, save to note again that hon. Members who have suddenly discovered its existence seemed to be silent about its dire consequences throughout most of the 18 years of the previous Administration.
We intend that the allocations of the health authorities and boards concerned will be adjusted to reflect the new arrangements and through that the different level of funding. It is intended that the adjustment should affect the actual level of spending on the patients concerned as is reflected in current commissioning arrangements.


For example, the allocation of an English health authority or primary care trust would be increased to reflect the current levels of spending on any Scots on the GP list. There is no question of money being lost to Scots patients because of the arrangements.
However, that is not to push the concept of capitation funding too far. It is not as though each individual is entitled to a fixed amount, which flows—ultimately—from the Barnett formula. Even under the previous Conservative Administration, the health service was not divided up with a fixed sum per head. A health authority, a health board or a primary care trust will use its funds to respond flexibly to the needs of its local population—whatever level of capitation each individual may, notionally, have attracted. That applies on both sides of the border.
It is worth bearing in mind that the existing arrangements have their drawbacks, which is why we want to take this action. Those arrangements take up time, energy and resources that might better be devoted to patient care. For example, at present, practices have to provide different arrangements for their English and Scottish patients. As I pointed out earlier, one practice reported having to liaise with six different teams of community staff to cover its scattered population.
A question was put about the letter from my predecessor to Dr. John Chisholm of the GPC—part of the British Medical Association. When my predecessor wrote that letter, the then Minister at the Scottish Office with responsibility for health wrote to the BMA in Scotland and gave similar guarantees. I am advised that those were repeated in guidance issued to local health care committees in Scotland on 8 February this year.

Mr. Hammond: Does the Minister know whether the assurances given by Scottish Ministers in this Parliament have been repeated by Ministers in the Scottish Executive since that body came into being?

Mr. Denham: I have no knowledge of that, although I shall look to the Under-Secretary of State for Scotland, my hon. Friend the Member for Western Isles (Mr. Macdonald), for information on that point. That matter is clearly not my responsibility.
I confirm that, fortunately for geography teachers and students throughout the country, there is no debate on which areas of England and Scotland lie adjacent to the border. There is no option in that matter. The English health authorities defined in the Bill will be North Cumbria and Northumberland and the Scottish health boards will be Borders and Dumfries and Galloway.

Question put and agreed to.

Clause read a Second time, and added to the Bill.

New Clause 4

CRITERIA FOR APPRAISALS BY THE NATIONAL INSTITUTE FOR CLINICAL EXCELLENCE

'The Special Health Authority known as the National Institute for Clinical Excellence shall make its appraisals of different treatments and clinical interventions on the basis of clinical efficacy or relative cost—effectiveness compared with alternative treatments or clinical

interventions for the same symptoms, but not on the basis of their affordability in relation to the funds available to the National Health Service.'.—[Dr. Harris.]

Brought up, and read the First time.

Dr. Evan Harris: I beg to move, That the clause be read a Second time.

Mr. Deputy Speaker: With this, it will be convenient to discuss the following: New clause 14—National Institute for Clinical Excellence (duties and consultation with public)— 
'.—(1) The Special Health Authority known as the National Institute for Clinical Excellence (the "Authority") shall meet in public.
(2) The Authority shall publish annually a report on its activities during the preceding calendar year which the Secretary of State shall lay before Parliament.
(3) The Secretary of State shall establish a public consultative committee in relation to the Authority, which shall have the duty of advising the Authority on the public's view on the priority to be accorded to different treatments and clinical interventions within the NHS.
(4) The constitution and membership of the committee mentioned in subsection (3) shall be such as the Secretary of State may determine in Regulations.'.

New clause 16—Protection of doctors' clinical freedom to prescribe appropriate drugs—
'.—The Secretary of State shall not exercise his powers to include a drug in schedule 11 to the National Health Service (General Medical Services) Regulations 1992 (as subsequently amended) in such a way as to restrict the circumstances in which the drug may be prescribed by reference to the different underlying causes of the symptoms for whose treatment it is clinically effective.'.
New clause 17—Cost or affordability not to be criteria for restricting prescribing of drugs—
'.—In issuing guidance on prescribing, or in exercising his powers to include a drug in schedule 10 (drugs and other substances not to be prescribed for supply under pharmaceutical services) or schedule 11 (drugs to be prescribed under pharmaceutical services only in certain circumstances) to the National Health Service (General Medical Services) Regulations 1992 (as subsequently amended), the Secretary of State shall not base his decision on the criterion of either the cost or the affordability of the drug in question.'.

Dr. Harris: I hope to introduce the new clauses relatively quickly, but at this point it is appropriate to pay tribute to the work of the hon. Member for Runnymede and Weybridge (Mr. Hammond), who in Committee paid great attention to the detail of our proposals—as I am sure he will do to these proposals. He did so assiduously during the Bill's Committee proceedings, while simultaneously fathering a child—or rather overseeing the birth of a child—[Interruption.]—There was some confusion as to that point in Committee.
More than mere scrutiny of the Government is involved in the new clauses. Like the other groups of amendments that we shall discuss in the near future, they show that some critical issues must be decided. On this occasion, the Liberal Democrats are raising those issues—of rationing in this group of new clauses; and of the hours worked by junior doctors and discrimination in the national health service in later groups. For more than three hours, we debated the border provisions in Scotland and we shall probably have a long debate on this and future groups of new clauses. One cannot help but think that the contributions of hon. Members—I am sure that those


contributions were always in order—were lengthy because of hon. Members' chagrin that they had not tabled such important new clauses as those that we are now discussing.

Mr. Bercow: Will the hon. Gentleman give way?

Dr. Harris: I shall do so in a moment.
It seems strange that, at the rate that we are carrying out our scrutiny of the Bill, we may well be discussing the hours of junior doctors in the middle of the night and spending a great deal of time discussing other matters that were covered at length in Committee. Nevertheless, although the House will want to discuss those issues, for those outside the House, it should be pointed out that something is going on—

Mr. Deputy Speaker: Order. We should not be worrying about what is to come; we need to worry only about the new clauses before us.

Dr. Harris: Thank you, Mr. Deputy Speaker. I was keen to point out that I will attempt to keep the substance of my remarks brief, because I know that Conservative Members will want to contribute—probably at length.

Mr. Hammond: I point out to the hon. Gentleman that any chagrin felt by Conservative Members is due entirely to the fact that the Government have allowed only one day for Report. We consider that to be wholly inadequate in view of the Bill's importance.

Mr. Deputy Speaker: Order. We need not go into those matters; we need only to worry about the group of new clauses before us.

Dr. Harris: The new clauses are about what the Government should and should not do in the rationing of treatment.

Mr. Bercow: rose —

Dr. Harris: I should be grateful if the hon. Gentleman would be patient so that I can get into the substance of my speech. I shall then willingly give way to him. On this Bill, we have a spirit of giving way—liberally, if he will excuse the expression.
New clause 4 provides that the National Institute for Clinical Excellence
shall make its appraisals of different treatments and clinical interventions on the basis of clinical efficacy or relative cost-effectiveness compared with alternative treatments or clinical interventions for the same symptoms, but not on the basis of their affordability in relation to the funds available to the National Health Service.
That is a key point and the new clause states the matter clearly. It goes to the heart of rationing, priority setting or managing the resources of the health service—whichever term we use.
New clause 14 refers to the need for openness and accountability and for public participation in whatever decisions are appropriately made through NICE.

Mr. Bercow: I welcome the fact that the hon. Gentleman is introducing this group of new clauses.

He has a long-standing interest in, and some considerable knowledge of, the plight of many of our constituents throughout the country as a result of rationing. However, will he tell the House why, when he is introducing these important new clauses, he is accompanied by only two of his hon. Friends? Is that because most Liberal Democrat Members are unconcerned about the problem of rationing and do not suffer its consequences?

Mr. Deputy Speaker: Order. I certainly do not want to hear a debate about the party make-up in the Chamber at present. We must discuss the new clauses.

Dr. Harris: I was going to say that I am aware of the interest of the hon. Gentleman in rationing. As he has acknowledged, he is aware of the interest of at least two Liberal Democrat Members who have raised that matter in Adjournment debates. They will be following the proceedings carefully.
New clauses 16 and 17 consider rationing of the drug Viagra from two different approaches. We take the Government to task for what has happened, in a way that is analogous to that in which the courts and the Government, by their own admission, feel that the issue has been mishandled. We also want to help the Government by introducing a measure to ensure that those mistakes are not repeated and that such rationing decisions are made fairly and rationally, rather than irrationally.
As I did in Committee, and as is customary, I declare an interest. I have a non-declarable interest as a fellow elect to a pharmaceutical company, under the Industry and Parliament Trust scheme, which gives Members of Parliament experience of private sector companies. I am attached to Glaxo Wellcome plc for that purpose, although I receive no remuneration. In addition, my interest in rationing took me on a study trip to the United States with NHS commissioners and clinicians to study the details of the association with the American Society of Clinical Oncologists, and the trip was funded by a pharmaceutical company.
We hope not to have to press new clause 4 to a vote, important though the issues are, because we raise those issues in a spirit of constructiveness and in a workmanlike manner. We hope that the Government will be able to reassure us that our fears are unfounded. Our great concern is that NICE will be a means for the Government to ration treatments, which is the term we use, or to deprioritise treatments out of the NHS in a way that is not politically accountable. The Minister knows that I have raised these concerns before, so his answer will be well rehearsed, but I seek specific undertakings from him.
7.30 pm
I hope that the Minister recognises that my approach to the National Institute for Clinical Effectiveness is not unreasonable.

Mr. Hammond: Clinical Excellence.

Dr. Harris: Sorry, the National Institute for Clinical Excellence. When I referred to the National Institute for Clinical Effectiveness, I was thinking of the Government's original press release on the special health


authority with that name, which was corrected from cost-effectiveness to clinical effectiveness, and then to clinical excellence.
The Liberal Democrats accept that treatments should be used only when they are likely to be efficacious and when they are effective. We have no time for an NHS that wastes money on prescribing drug treatments or carrying out operations that are not of clinical benefit to the patient, or where the adverse effects of the medication are likely to outweigh any clinical benefit that the patient may receive. Clearly, there is a need for national standards, not only to get rid of what the Government rightly describe as unacceptable variations in the delivery of treatment, but to ensure that treatments that are a waste of money are not carried out through best practice not being disseminated sufficiently widely.
We would go further on the issue of cost-effectiveness. We recognise that the NHS has limited funds, although we would argue that it should be better funded than even the Government have managed over the past two years. Given that funds are limited and that there is a great need for services, it would be wrong for health authorities, trusts and clinicians to prescribe drugs or offer treatments that are more expensive than other treatments for the same condition or symptoms, but no more effective. It is sensible to consider the relative cost-effectiveness of treatments and to ensure, given the NHS's limited budget, that money is not spent needlessly. I hope that that is common ground between us.
We have two concerns, however, on which the Government have yet to reassure us. The first is whether the measure of cost-effectiveness will be wide enough and, if it is sufficiently wide, whether it will be fair, especially to pharmaceutical companies and in respect of drug treatments that are relatively new. Our second concern is that, even if the test of cost-effectiveness is met, the Government will use NICE to ration on the basis of affordability drugs that are highly effective, efficacious and relatively cost-effective, but whose widespread effective and cost-effective use would have implications for NHS budgets. We acknowledge that there is a need for tough decisions to be made on those issues, but the Government must publicly announce those decisions, not shelter behind NICE.
We are concerned that, so far, the Government have not ruled out NICE making its recommendations on the basis of affordability, even in respect of treatments that are effective and cost-effective. We are also concerned that the chairman of NICE, Professor Rawlins, in his evidence to the Select Committee on Health, did not rule out the possibility that he might be forced—against his will, I am sure—to make recommendations based on affordability in respect of treatments that would otherwise pass the effectiveness and relative cost-effectiveness tests. I see that the hon. Member for Runnymede and Weybridge shares my concern.
The issue of efficacy is not all plain sailing, which is why it would be of great benefit to the House if we had a debate on NICE. However, I shall not take up time considering such matters in detail now. In respect of the efficacy of new treatments, it will be difficult for NICE to be fair to patients and to treatment providers. There are several new treatments whose efficacy dawned on the NHS rather late. For example, some of the new HIV treatments were never felt to be particularly effective on their own; but, a significant time after their introduction,

they were found to be highly effective and cost-effective if used in combination. If their use on the NHS had been prevented, NHS patients would never have benefited from that combination therapy and, in this country at least, doctors might never have found out that the drugs were so useful in combination. There are significant concerns about the way in which NICE will judge the efficacy of new drugs.

Dr. Nick Palmer: I, too, should declare an interest in that, from time to time, I advise Novartis, although I am not sure that that company would agree with the question that I am about to ask. Does the hon. Gentleman agree that the approach taken today, whereby such decisions are being made by dozens of individual units around the country, is not necessarily superior to having one body deciding centrally? Does he also agree that it is difficult to consider the question of cost-effectiveness completely separately from that of clinical effectiveness, because it is only one of several factors? It is rather artificial to expect NICE completely to ignore that aspect.

Dr. Harris: I think that I have already covered the second part of the hon. Gentleman's question. As for his first point, it is not a question of centrally set guidelines versus the relatively quick or slow uptake of new treatments in various parts of the country. Clearly, having NICE lay down what should or not be prescribed and then insisting on its guidelines being followed—incidentally, the level of insistence is not clear—will mean that a treatment is either quickly introduced everywhere or not introduced anywhere. My concern is that the data on which that uniform, NHS-wide decision is based will not be complete and that the wrong decision will be made and its effect last for all time, or for a significant period of time until the decision is re-examined. Such an approach might well have held back the introduction and use of the HIV drugs to which I referred.
Although we support the idea that NICE should examine efficacy, costs and prescribing practices in respect of new drugs and treatments, we recognise the difficulties with data on efficacy. Another example of that is ACE—angiotension converting enzyme—inhibitors. They were felt to be of limited clinical use when they were first introduced, and certainly when I was a medical student, but were later found to be highly effective for conditions other than those for which they were originally used. That discovery would not have been made had they not been prescribable on the NHS on the basis of more limited evidence.
There is concern that the way in which NICE will consider cost-effectiveness will be too pure—that it will not consider "relative cost-effectiveness", which is the wording in the new clause, but will use some pure measure of cost-effectiveness without stating how that measure should be arrived at. There are many measures of cost-effectiveness, such as the numbers it is necessary to treat in order to achieve a valuable clinical effect in one patient, or the cost of a treatment, perhaps combined with the costs per life-year saved or per quality adjusted life-year. There is a series of such measures, but the NHS is not experienced in assessing them.
Patients, patient groups and the pharmaceutical industry are concerned that NICE will seek large amounts of data that are not readily available. The new clause makes it


clear that we should be considering "relative cost-effectiveness", where it is measurable, against existing treatments. When the data are poor, the new treatments should be given the benefit of the doubt.
An example is the drug erythropoetin, which is used to stimulate the production of red blood cells in patients who are anaemic and suffering from renal failure. That treatment was very expensive when it was first introduced. It was believed not to be cost-effective, and its availability was extremely limited. However, it proved to be relatively cost-effective in preventing hospital re-admissions and negated other costs associated with chronic renal failure. The early prevention of that drug's prescription may have hidden its relatively high cost-effectiveness.
Our main concern is which budgets NICE will examine when measuring cost and benefit. For example, the new anti-psychotics—the so-called atypical anti-psychotics—used to treat schizophrenia are much more expensive than the old reliables, such as haloperidol. There is no justification, on a purely cost basis, for prescribing the atypical anti-psychotics. However, it is now well recognised that the side-effects of the older drugs are so great that compliance is poor. Patients do not take them; they then suffer acute relapses and require hospitalisation, which generates more costs. The new drugs are tolerated better, and should therefore be prescribed.
We are concerned that the cost-effectiveness data will comprise only NHS drug budgets, not broader NHS treatment budgets. In the case of Alzheimer's disease, we are concerned that the measure will be NHS budgets rather than the wider social care budgets. Even if wider budgets across the health and social care fields were examined and the data were available—it may be difficult to obtain without investment in research and development, which the Government have cut in the first few years of this Parliament—there is concern that NICE will not take account of social security budgets and the benefits to the nation of having healthy people working and paying taxes.

Mr. Fabricant: Does the hon. Gentleman not consider that there are parallels with a cost-benefit analysis that the Government should undertake regarding the free provision of nicotine replacement therapies in order to reduce the cost to the national health service of treatments for cancer and pulmonary and other dysfunctions caused by tobacco smoking?

Dr. Harris: I agree with the hon. Gentleman. My point is reinforced by Stephen Thornton, who is quoted in an excellent booklet produced by the Association of the British Pharmaceutical Industry and authored by Chris Mihill, a well-regarded former medical correspondent on The Guardian. Stephen Thornton, the chief executive of the NHS Confederation, is reported as saying that he
doesn't think the savings from other budgets, such as social services or social security, will revert to the health service, even if they could be fully quantifiable.
The booklet quotes him as follows:
If patients go back to work and pay taxes, the money goes to the Treasury, and when does the health service see that? It's an argument the Health Department must have with the Treasury,

that investment in the health service produces economic benefit. But at the moment, from a GP and trust point of view"—
I think he also means from a commissioning point of view—
if it's outside the health sector, it's money which we can't have.
Mr. Thornton argues that that cost-effectiveness calculation should not be made, or is not currently being made. I fear that the wider arguments that would prevent false economies will not be made unless the Government pay particular attention to the workings of NICE.

Mr. Bercow: The hon. Gentleman has largely dealt with the point that I proposed to raise. Does he agree that, on the basis of ministerial pronouncements thus far, it would appear that Ministers intend to adopt a very narrow interpretation of cost-effectiveness? Although they have not excluded the consideration of social factors, the Minister has attempted to play them down on several occasions. That is a worrying portent for the future.

Dr. Harris: I have read the Minister's responses to Adjournment debates about multiple sclerosis, and I have listened carefully to his comments in previous debates. I remain optimistic that he will recognise the concerns that we have highlighted and will confirm now that, in their response to the consultation on NICE, the Government will give the institute adequate resources so that it may undertake true cost-effectiveness work. Narrow cost-effectiveness measures will not be fair to patients or to those seeking to develop new treatments.
Regardless of how the Minister deals with the problem of cost-effectiveness, I hope that it is clear to all—I trust the Minister will agree—that it cannot be right for NICE to set out guidelines preventing or advising against use by the NHS of a drug or other treatment when it is effective and cost-effective but when the take-up of that treatment would adversely affect the NHS budget. That is a consideration for Ministers, but NICE would be abusing its power if it were to restrict the use of cholesterol-reducing drugs, for example, that would prove both effective and cost-effective in the long run by reducing cardiovascular mortality and morbidity simply because it would have significant cost implications for the NHS.
If such restrictions must be made, the Government should say that the NHS cannot afford to provide the treatments out of current resources. We could then debate publicly how much the Government should spend on the NHS or, as the Conservatives would have it, how much use those who can afford to should make of the private sector in order to create more space in the NHS. We believe equity dictates that there should be much more funding for the NHS, but that is a matter for another debate. The key point is that the public have a right to consider that issue. Even if new clause 14—to which I shall turn in a moment—is agreed to, I do not think the public will have much of an idea about the pronouncements of academics and others from NICE.
I believe that the Government adopted the correct position on Viagra. That was a pure case of rationing on the grounds of affordability, and the Government were right not to impose restrictions through a covert health service circular or through some quango, although there were some problems. I seek the Minister's assurance—we


have not received such an assurance from the chairman of NICE—that the institute will not apply the criterion of affordability when considering effective and relatively cost-effective drugs. I will be happy if the Minister will provide that assurance. I know that many, if not all, clinicians, as well as those who take a sensible and mature approach to the difficult question of prioritisation and deprioritisation, will be relieved to hear that the Government are taking a responsible view of where political accountability lies.
We discussed proposed new clause 14 in the Third Standing Committee on Delegated Legislation on 10 March this year, when I asked the Minister whether meetings of NICE would be open to the public. He said that I was
right to say that the regulation as drafted does not require public acc ess to meetings of the institute's board. There is a case for that in the climate of openness and transparency, as he said, although he also acknowledged that issues of confidentiality would need to be protected.
He continued:
If the matter proved in practice to be a problem, it could be dealt with by further regulation.
I say to the Minister that it is not a question of whether there is a problem in practice, but making public access subject to matters of commercial confidentiality should be a default principle. The Government should ensure that meetings are held in public unless there is a reason why they should not be. I look to the Minister to reassure us that the public will normally be admitted to the board's meetings and that the Government will introduce regulations to ensure that, so that I will not need to press that part of new clause 14.
Subsections (3) and (4) of new clause 14 set out a way in which the public can be involved in decisions relating to NICE. It is important that the public have a say in the issues that the institute should consider because we have to find a way to involve the public in decisions on rationing.

Mr. Bercow: The hon. Gentleman is making a powerful point about public involvement and the need for accountability. Does he agree that the machinery of consultation and public involvement is likely to be effective only in so far as there is a guarantee from the Government that there will not be private words between Ministers and NICE, the purpose and effect of which will be to disregard the outcome of the consultation and, in other words, to make it a sham? Do we not need to be reassured that under no circumstances will that happen?

Dr. Harris: That is a very important point. The decisions about which treatments, processes and drugs the institute should consider should be made openly. There should not be seen to be collusion between what is supposed to be a semi-independent health service body—a special health authority—and Ministers. If Ministers are to give directions, which they may feel is their right, they should do so openly and in consultation with the public.
Many people have called for the public to be more involved in such decisions. In the Standing Committee that considered the statutory instrument, to which I have already referred, the Minister said:
I confirm that it is important that patients' interests are represented in all NICE's work. From a patient's point of view, quality has sometimes been neglected in the drawing up of

professional guidelines in the past."—[Official Report, Third Standing Committee on Delegated Legislation, 10 March 1999; c. 18–19.]
By having not only lay representatives on the institute's board but a public consultative committee for the authority, we shall ensure that the institute's deliberations are seen to be publicly accountable in a way that, with the best will in the world, one could not guarantee if there were only a cosy arrangement between the Minister and the institute.

Mr. Hayes: The hon. Gentleman is making a good case for a wider debate about this matter, and he is right to do so because some of the institute's judgments will not be clinical but ethical or moral in a broad sense. Is that open and public debate helped by Ministers' continual denials that those restrictions are not already operating? The truth is that there is already rationing. One can euphemistically call it strict management of resources, as the hon. Gentleman has done—I understand why he has done so—but continual denials that those choices are already being made does not help the process of public, open and honest debate that the hon. Gentleman is advocating.

Dr. Harris: I agree with the hon. Gentleman, and both Opposition parties have initiated debates on that. There is scope for a separate debate on the workings of the national institute, but I am keen to make progress now. I hope that by making points that hon. Members agree with, I shall enable them to restrict their comments so that we can make quicker progress.
On public accountability, the Consumers Association's magazine Health Which? pointed out that, in its survey, three quarters of the people who were interviewed felt that the public should have a say in which services were available on the NHS, but only a third of the 35 health authorities surveyed made any mention of public consultation in their material.
Oxfordshire has a priorities forum that is open to the public, and I attend that forum to find out exactly what is happening in health service rationing. I can assure the Minister that the word "rationing" is used by all the people in that forum, whether they are professionals or lay people. I know that Buckinghamshire and other health authorities try to involve the public. However, that is not sufficient public involvement. There should be a national scheme to mirror those local arrangements. We support the Consumers Association's call for wider public involvement.
I press on now to new clauses 16 and 17, which relate to the way in which the Government have used the scheduling procedure in the National Health Service (General Medical Services) Regulations 1992 to restrict the availability of drugs on the NHS, particularly Viagra. I make two criticisms of the Government in speaking to those new clauses. My reasons for tabling new clause 17 echo my arguments about the Government using affordability as a criterion for using schedule 10 or 11 of those regulations on the basis of cost or affordability.
Schedule 10 relates to drugs that are not available on the NHS, and schedule 11 relates to drugs that are available only under limited conditions. Since their introduction, those procedures have traditionally been used, in the case of schedule 10, for drugs that are not


efficacious, or are no more efficacious, than cheap alternatives and, in the case of schedule 11, for drugs that are effective only in treating certain conditions. It is not the case that certain conditions are specified to control cost. The use of those schedules has been based on effectiveness and, even if drugs are effective, on strict relative cost-effectiveness.

Mr. Fabricant: Does the hon. Gentleman have a view, as his party's spokesman or as a former houseman in a hospital, on the effect of prescribing generic drugs that may be cheaper but have side effects very different from those of the main drug for which they are a substitute?

Dr. Harris: I do have views on that, but I shall not express them in this debate. If the hon. Gentleman sees me afterwards, I will be happy to go over those issues. There are issues of generic substitution but they do not relate to these new clauses.

Mr. Fabricant: They do.

Dr. Harris: No, they are different, and controversial, issues, although I understand the point that the hon. Gentleman is trying to make.

Dr. Stoate: I seek clarification from the hon. Gentleman. He seems to be telling us that drugs that are proscribed from being used for certain conditions under schedule 11 are simply not effective in treating those conditions, but that is not the case and it is not borne out by my knowledge of medicine. For example, a severe case of sunburn may be due to overexposure to the sun or to photosensitivity. Sunblock will work in both conditions, but schedule 11 specifies that sunblock should be prescribed only in clear cases of photosensitivity and should not be prescribed as a cosmetic treatment to allow people to spend more time in the sun. Another example is scaly scalp condition—

Mr. Deputy Speaker: Order. The hon. Gentleman should know that interventions should be brief, so perhaps he will allow the hon. Member for Oxford, West and Abingdon (Dr. Harris) to respond to that point.

Dr. Harris: The hon. Gentleman is making the same point as I am. The scheduling of drugs for certain conditions is based on their effectiveness and cost-effectiveness. I agree with the examples that he has given. Those schedules do not include drugs that are effective and relatively cost-effective for a recognised clinical condition and have never been used for that purpose. However, that is exactly what the Government plan to do from 1 July for Viagra. There is no doubt that the Government accept that Viagra is effective and also relatively cost-effective, but the increased demand for an acceptable and cost-effective treatment creates problems of affordability for the NHS. The Government are misusing schedules 10 and 11 for such a drug.
As I have said before, if the Government suspect budget implications as a result of increased need for a drug, it is right that they make an announcement. Our concern is not that the Government made such an announcement, but that they did so irrationally. Part of that irrationality was

the misuse of schedules 10 and 11. The criteria should have been based on effectiveness and relative cost-effectiveness, not on pure cost or affordability. That is why we have tabled new clause 17. My criticism of the Government on that matter has been shared by many clinical authorities.

8 pm

Mr. Fabricant: I do not like to press the hon. Gentleman—he is very reasonable—but surely the very new clause that he has tabled relates to generic substitution. The Government would argue at times that cost-effectiveness could be secured by prescribing a substitute for a drug at the expense of clinical side effects that may be detrimental to the patient.

Dr. Harris: I do not want to be drawn into the question of generic substitution simply because it is controversial whether the differing availability of generic drugs and patented drugs causes side effects. That is a drug-specific matter. Regardless of the details of generic substitution, I am talking about the general principle—I hope that the hon. Gentleman will accept this—of the Government's misuse of schedules on effectiveness and cost-effectiveness in order to get themselves off a hook.
As the Government may know, new clause 16 is a direct criticism of the way in which they chose to ration Viagra. If accepted, it would prevent the Secretary of State from doing what he did with respect to Viagra. I think that the NHS, lawyers and the Department of Health would be grateful for such legislation, since the Government would be prevented from breaching what I consider to be a doctor's ethical duty: to prescribe a drug that he or she considers to be effective, regardless of the origin of the complaint from which the patient suffers, if, in each situation, the drug is equally effective.
The Minister will know that there was a court case concerning the interim guidance and that the final guidance that the Government are producing under schedule 11 almost certainly cannot be challenged legally. New clause 16 is not about the legal judgment but about whether the Government are rational in saying to a group of patients, "However effective and cost-effective this drug may be in treating your recognised condition, you will not be given it because your condition stemmed from"—for example—"cardiovascular or psychiatric causes." As a result of the Government's creating two lists and direct discrimination, a diabetic, for whom the drug may be less effective and cost-effective, may well qualify for the drug.
We shall come in due course to another group of new clauses that address discrimination. The Government have said that they do not believe that the NHS should be discriminating irrationally. We have agreed, I hope, that where such rationing occurs, there should be a clinical basis for it. In the case of Viagra, the basis was cost. The Government wanted to ensure that only 15 per cent. of potential patients were treatable, and therefore chose conditions that accounted for only 15 per cent. of patients.
It would have been more rational to give hospitals, primary care groups or individual GPs a budget, enabling them to use their clinical judgment to treat the 15 per cent. of patients who would benefit most from such treatment. The Government should not lay down rules. To give them credit, they did say that only 15 per cent. of potential


patients would be treated; that is part of the openness and accountability in rationing decisions about which we talked earlier. It was entirely wrong, unfair, inequitable and discriminatory for the Government to do what they did over Viagra.
In Committee, I pressed the Minister on this point and asked whether, if such a situation arose again, he or his right hon. Friend the Secretary of State would use the same technique in order to ration. He reassured me partially that he thought that unlikely—I think we were still awaiting the outcome of the legal matter at that point. I should be grateful if the Minister confirmed that discrimination on the basis of cause of condition rather than effectiveness of treatment will not be the basis on which future rationing decisions are made. If that reassurance cannot be given, we shall press new clause 16 to a Division.

Mr. Fabricant: Does the hon. Gentleman accept that the Minister, just like his boss the Secretary of State, will not allow the word "rationing" to cross his lips? They will not even admit the existence of rationing in the health service, so any reassurance that the hon. Gentleman may have been given would have certainly omitted that word.

Dr. Harris: The hon. Gentleman knows that I agree with those sentiments, which have been expressed before by other hon. Members. I hope that we shall not have a long discussion on the Government's refusal to use the dreaded "R" word, although I fear we will. Despite the fact that the Government refuse to call a ration a ration, I am trying to make a constructive point. I very much look forward to the Minister giving an assurance that prioritisation or deprioritisation or resource management, or whatever he calls it, will not be conducted on such an irrational basis again, and to his accepting the principle of new clause 16.
The new clauses go to the heart of the rationing issue. They identify many of the key points that the Government have not yet clarified, despite hours of debate both in Committee and on the Floor of the House. I know that the Minister has a deep understanding of these issues, so I look forward to his offering considered reassurances. The matter is set out clearly on the amendment paper. He will be judged by the health profession and those involved in the NHS on the satisfactory nature of his answers.

Mr. Hammond: It is very appropriate that the hon. Member for Oxford, West and Abingdon (Dr. Harris) ended on an explicit discussion of rationing and whether we should call it by its name, because this debate on Report is on the question of rationing. Many hon. Members present will regard the question of rationing and the attempts to rationalise rationing without ever admitting that it exists as one of the most important issues to address in considering this Bill.

Mr. Fabricant: I am sorry to interrupt my hon. Friend so very soon in his peroration, but does he not find it ironic that it took a High Court judge to tell the Secretary of State that rationing—in that case of Viagra—was wrong, but that the Secretary of State still cannot bring himself to use the word?

Mr. Hammond: My hon. Friend is entirely right. I shall return to that matter in a moment.
I thank the hon. Member for Oxford, West and Abingdon for acknowledging the role that the Conservative Opposition played in Committee in seeking to widen the debate on this Bill to embrace the very important issue of rationing. It was not as easy as one might have expected. Although the clauses before us deal specifically with the National Institute for Clinical Excellence, which is indeed a key part of the Government's machinery for rationing service delivery in the NHS, many hon. Members who have not had the privilege of serving on the Committee that considered the Bill, and perhaps may not have studied the Bill in great detail, might be rather surprised to discover that NICE is not a child of the Bill. It was introduced by the Government by means of a statutory instrument. Therefore, it is only by means of new clauses such as new clause 4, which seeks to restrict the scope of NICE' s operation, that we can use this Bill in any way to bear on those very important issues.

Mr. Bercow: Given my hon. Friend's deserved reputation as an intellectual giant in the House, I wonder whether he can clarify a matter that has puzzled me for some time, upon which I feel sure that he has dwelt in reflecting on the Bill. In his judgment, what is the difference between rationing, which the Government disavow, and prioritisation of resources within a finite budget, of which they apparently approve?

Mr. Hammond: My hon. Friend asks a very good question—one which I put to the Minister of State—

Mr. Fabricant: Another intellectual giant.

Mr. Hammond: Indeed, as another intellectual giant. My hon. Friend asks a question which I put to the Minister in the Committee on the statutory instruments that introduced NICE. I feel a little sorry for Ministers who have to deal with this question time and again, because they are intelligent people who well understand the situation in which the NHS operates. They understand as well as we do, as well as the BMA, as well as the royal colleges, as well as the Patients Association, that of course there is rationing in the national health service. That is nothing to be ashamed of. We should accept and acknowledge that, and then we might have a sensible debate about how best to ensure that that rationing occurs in a way that is fair, transparent and rational.
The absurd situation that we all find ourselves in this evening is that the Government have created, in NICE, a mechanism that will make more rational the imposition of rationing in the national health service, but they cannot proclaim that success because they will not admit that there is any rationing in the NHS. Indeed, my right hon. Friend the Member for Maidstone and The Weald (Miss Widdecombe), after an exchange at the Dispatch Box a few months ago, asked the Minister for Public Health outright the question,
Is there rationing or is there not?
and the answer came,
No."—[Official Report, 15 December 1998; Vol. 322, c. 746.]
We cannot have a more explicit statement of Government policy from a Minister at the Dispatch Box


than that, and yet, absurdly, although every commentator—qualified or not—recognises that there is rationing in the NHS, the only party that does not is Her Majesty's Government.
In defence of the Minister of State, I am certain that he and his colleagues—the Minister for Public Health and the Under-Secretary—privately recognise, in their own intellectual analysis of the situation, that of course there is rationing, and find having to keep denying it publicly deeply embarrassing.

Miss Widdecombe: In case my hon. Friend was prepared to be generous and felt that the Minister for Public Health was put on the spot by my question and said no by accident, would he now like to consult written answers in which he will find that the Secretary of State has said that there is no rationing in the health service?

Mr. Hammond: I was not suggesting for a moment that the Minister for Public Health might have answered no through inadvertence or for some other reason. I am saying that, having dealt with the Minister of State for several months on many issues and having had a chance to appreciate his rational and analytical approach, I cannot believe for a moment that he really believes that there is no rationing in the NHS. I was merely pointing out that I find it deeply embarrassing that Ministers have to keep repeating the nonsense that there is no rationing—but not so deeply embarrassing that I shall not ask them that question again in due course.

Mr. Bercow: On the "pedantry pays" principle, I am anxious that we should be accurate as regards the record of oral questions. Am I right in thinking—my right hon. Friend the Member for Maidstone and The Weald (Miss Widdecombe) will probably correct me if I am wrong—that the Minister for Public Health insisted that there was no rationing, not once in answer to one question, but on no fewer than three occasions in answer to three questions from my right hon. Friend? My photographic memory is not serving me on this occasion.

Mr. Hammond: My hon. Friend is right, and that assurance that there is no rationing has been repeated by the Minister of State and the Secretary of State. However, I have not yet come across any other body—I mean that in the literal sense—that shares that view. Almost everyone else that I have come across accepts and acknowledges that there is rationing and believes that we should be discussing how to deal with that rationing.

Mr. Fabricant: Will my hon. Friend give way?

Mr. Hammond: If I may, I should like to pay tribute to the hon. Member for Oxford, West and Abingdon for raising those issues tonight. He has done us a service in doing so. They are important issues, and the hon. Gentleman is well qualified to raise them. Apart from being instantly recognisable as the only member of the Liberal Democrat party not yet to have declared himself in the leadership race, he is a former junior doctor so he speaks with some authority on such matters.
Opposition Members have noticed that the Bill is about separating power and responsibility: about moving power upwards to the Secretary of State through an ever more centralised system of directions and determinations, so that the Secretary of State has more and more power at his fingertips to control every minute part of the operation of the NHS, while at the same time delegating down responsibility for the results of actions over which the bodies held responsible have a decreasing amount of power or influence.
We have been very focused on the issue of rationing. The new clauses that the hon. Member for Oxford, West and Abingdon has introduced tonight focus us on the wider issue of rationing. In that context, he has picked two specific examples of rationing as it currently exists and is proposed to exist—the role of NICE and the use by the Government, in dubious circumstances, of schedules 10 and 11. I shall disappoint some of my hon. Friends by pronouncing "schedule" as the hon. Member for Oxford, West and Abingdon did—with a hard c—but it is a habit that I, too, find difficult to drop.
It might be useful if we look at that bogey word, "rationing", because it is not really as awful as Ministers' constant denials of it might have us believe. Conservative Members believe that there is no shame in acknowledging that there is rationing within the NHS. There has always been rationing within it. For the record, there was rationing within the NHS during the period of the previous Conservative Government. We do not deny it, and have not sought to deny it.

Mr. Denham: I wonder whether the hon. Gentleman would explain a question that has been worrying me, which is why, for 18 years under Conservative Governments, not a single Conservative Minister—or, as far as I know, Conservative Member of Parliament—said that there was rationing in the health service.

Miss Widdecombe: I did.

Mr. Hammond: My right hon. Friend says from a sedentary position that she did. Perhaps the hon. Gentleman did not ask the right questions. I regret that I was not here at that time to observe what was going on.
Those of my hon. Friends who happened to be watching last night's television coverage of the results of the Euro-elections may have seen Peter Snow conjure up a rather whizzy little graphic that showed the change of the Government's popularity rating on various different issues, and the issue on which the Government's confidence rating among the British population had declined the most since May 1997 was health. The graphic showed that very neatly.
The Minister might reflect upon the extent to which reiterating a statement that the vast majority of the British public know from experience to be untrue, and which the vast majority of the professions involved know to be untrue, may have, in no small part, led to the significant decline in the British public's confidence in the Government's health agenda.
Rationing is an undeniable fact. Professor Sikora of the World Health Organisation stated that terminally ill cancer patients have to pay thousands of pounds for life prolonging drugs because of lack of cash. It has long been the case that doctors prioritise cancer cases on the chances


of an effective cure or a lengthy prolongation of life, but the Government still deny that cancer services are rationed.
Breast cancer patients are paying £12,000 for a six-month course of Taxol. Many hon. Members have examples from their constituency correspondence of constituents who have had to go to extreme lengths, in some cases having to sell houses, to pay for life chance-enhancing drugs that are not available from the health authority where they live.
Patients with cancer of the colon are paying £8,000 for a course of Ironotecan. One of the hazards of engaging in a debate on rationing with people who have a specialist knowledge, such as the hon. Members for Oxford, West and Abingdon and for Dartford (Dr. Stoate) is that one must wrestle with the pronunciation of such unpronounceable words. Lung cancer victims must find £6,000 for a course of Gemcitabine.
Professor Thomas from the university of Surrey, which is close to my constituency, and a specialist cancer referral centre that serves cancer patients from my constituency, states that she has cash disputes with the NHS on behalf of patients every two or three weeks.
The concerns that have been voiced regarding drugs for the treatment of people with psychotic illnesses, as we heard, are even more notable. In many cases, drugs developed in the 1950s are preferred not only over the latest atypical anti-psychotics, but even over drugs developed in the 1970s, such as Clozapine.

Mr. Hayes: That highlights the issues raised by my hon. Friend the Member for Lichfield (Mr. Fabricant) in his intervention—the definitions of efficacy and of effectiveness. When we speak about effectiveness, we may be speaking of a cure, but we should also consider the route to the cure, and the effect on the patient during treatment. In measuring effectiveness, we must take such aspects into consideration, and the Government are simply not doing so.

Mr. Hammond: My hon. Friend raises an interesting question, which could take us still wider on the issue of rationing: what are we measuring when we look at the outcomes? What are we measuring as a benefit—extension of life, or extension of life with a certain quality attached to it, as the hon. Member for Oxford, West and Abingdon said? It is legitimate to ask such questions, and it would be legitimate for us all to engage in a sensible debate about them, but we cannot do so while the Government insist that no rationing exists.

Mr. Fabricant: May I ask my hon. Friend a philosophical or historical question? Does he recall that in the 19th century, many great medical schools were unable to offer cures for certain dysfunctions, but they thought it important to diagnose a dysfunction such as diabetes, for which no cure was known until the 1920s? Without being able to identify a problem, one cannot seek a solution. Until the Government identify the fact that rationing exists, there cannot be a sensible debate about how we solve that problem.

Mr. Hammond: My hon. Friend's suggestion of using an evidence-based medical approach to the Government's problem of acknowledging rationing is interesting, but, as

I said, I imagine that the Government have already identified the problem, but have boxed themselves into a corner. They cannot acknowledge it and engage in a sensible debate. I expect that, to their credit, many Ministers greatly regret that they are in that position. When they could be addressing the issues, they must instead deny the fact that rationing exists at all.
Beta interferon is a favourite example in the House whenever rationing is debated. Many hon. Members have harrowing tales of availability that is often limited by crude numbers, so that patients who need treatment with beta interferon may have to wait for someone else to die before they can get on to a course of that treatment.
Rationing has manifested itself in many other ways throughout the NHS. Operations for many minor procedures in many health authorities have ceased to be available. Operations on lipomas, sebaceous cysts and non-acute varicose veins are unlikely to be available in many health authorities across the country. West Hertfordshire health authority has a list of 32 operations and treatments that it will not provide other than in exceptional circumstances.
The waiting list is a form of rationing—rationing by inconvenience. Reducing the convenience of the service provided and making people wait for the provision of a treatment constitutes an additional form of rationing.
In the NHS that the Government are seeking to create through changes in primary care, increasing pressure will be directed at general practitioners to restrict their prescribing practices to meet the budgetary needs of the primary care trusts or primary care groups of which they are members, or to fall into line with prescriptive guidance from mechanisms such as NICE.

Mr. Bercow: Does my hon. Friend agree that because Ministers are not prepared to acknowledge the indubitable fact that rationing exists, that has led them down the dark alley of making invidious comparisons of relative cost-effectiveness? Does he agree that even at this, the 59th minute after the 11th hour, it would be helpful if they would abandon that pretence so that a genuine and meaningful debate, rather than a bogus one, about the relative cost-effectiveness of different treatments could take place?

Mr. Hammond: My hon. Friend raises an interesting point. There is a place for the important debate on relative cost-effectiveness. Although we need to examine the overall resource constraint under which the NHS labours, we all have a duty to ensure that the money available in the NHS, whatever the amount is, is spent in the most effective way.
Where there are different treatment approaches to the same symptoms, and one of them can be shown to be more cost-effective than another, that is precisely the sort of issue that a dispassionate, apolitical, technical institute should consider and report on. That is quite different from allowing that institute to recommend that a treatment should not be available at all because it is too expensive to the NHS and cannot be afforded.
The new clause specifically draws that distinction between what I think of as the technical function of assessing the relative cost effectiveness of different alternative treatments or clinical interventions for the same symptoms and assessing the affordability of a given


treatment or intervention in relation to the overall total funds available to the national health service. I would characterise that as a political rather than a technical function.
That is what I had in mind when I mentioned that there is a trend or a tendency within the Bill to devolve power upwards to the Secretary of State and responsibility downwards to other NHS bodies. The technical process of evaluating the relative cost-effectiveness—I emphasise relative—of different treatments or clinical interventions is properly something that the Secretary of State can devolve to a body such as NICE. In an environment where the Secretary of State acknowledged that there was overall rationing and that there was a resource constraint that limited the amount of treatment available, the input from the institute would be vital information in moving to the next stage, which is to ask who gets what within the overall resource constraint.
8.30 pm
We are concerned because, given the Government's refusal to acknowledge that there is an overall resource constraint, the role of NICE, which should be a technical, dispassionate and apolitical one, exactly as the new clause suggests, risks becoming politicised, with the institute being encouraged or forced to make judgments about what should or should not be available on an absolute basis, in the context of assessing treatments and drugs against the overall budget that the NHS has available to it.

Mr. Hayes: The dilemma that my hon. Friend is describing—the contradiction in the structure—coupled with the lack of clarity or openness in the debate, will encourage the public to blame NICE or, more likely, the local hospital or the local GP, rather than taking a view that the Government should have made wider strategic judgments. The Government are not simply setting up something that is contradictory and paradoxical. Instead, they are passing the political buck. People will be angry and they will direct that anger at professionals rather than at politicians. My hon. Friend is putting the case in an informed way, but I will put it rather more bluntly when dealing with my constituents in my case work.

Mr. Hammond: My hon. Friend is right. If he reads the medical press, he will see that general practitioners have rightly recognised that they are being lined up to take responsibility for rationing decisions and to bear the brunt of the complaints and criticisms that he anticipates his constituents will raise with him. My hon. Friend is right to identify the issue.
Power resides with the Secretary of State throughout the Bill, but it is someone else's responsibility to answer for the delivery of the service. That is the antithesis of transparency and openness in government, where power and responsibility should be seen clearly to reside together. The overall issue of rationing and how the available resources within the NHS are to be allocated is intrinsically a political decision. There is no shame in making it, but it is not a decision that can be shunted off on to an institute that has been set up to make evaluations and to report on the relative merits of one thing or another.
Neither is it a decision that can be made by doctors on the basis of clinical priorities without a political framework being placed around them so that they know

the context in which they are required to make that clinical prioritisation. It is relatively simple to ask doctors to place in order of priority a group of patients in terms of who is the most needy or deserving of treatment in a particular circumstance. However, it is not reasonable to ask doctors to determine where the cut-off point should come in allocating the available resources. The amount of the available resources is, of course, a political decision. The determination of the level of those resources must reside with the Government. There responsibility must also reside for deciding how the impact of rationing will fall.
The new clause correctly defines the role of NICE if we take the Government entirely at face value and if we take their assertions that the institute will spread best practice and will examine the relative cost-effectiveness and clinical effectiveness of different treatments and interventions so that the NHS can operate in a more logical and rational way, so that it does not waste money on things that are relatively ineffective or expensive for a given outcome.
If the Government are to be believed, and if their assertions about their intentions for NICE are to be taken at face value, they should have no difficulty in accepting new clause 4, but we have long believed that they have another agenda for NICE. They intend to create through NICE a quasi-clinical respectability for the rationing decisions which increasingly will have to be made.
As the hon. Member for Oxford, West and Abingdon has already pointed out, we have to consider not only Viagra and other well-known drugs that are already available, at least in the technical sense, but drugs that we all know are coming along, although they are not yet even theoretically available on the market. Such drugs will be very expensive, but they could change quite radically the outcomes for people in certain disease groups or with certain conditions.
The chairman of NICE, Professor Michael Rawlins, has already openly admitted that the institute may have to recommend that a treatment or a drug should not be available on the NHS because of the overall constraint on resources and the impact that such a product or treatment would have on the NHS budget.

Mr. Bercow: My hon. Friend is making an important point and I should like to clarify one aspect of it before he moves on. Does he agree that the only way in which the Government can refute the charge that he has made about their reasoning in creating NICE is to confirm this evening that there will be no private discussions between Ministers and the chairman of NICE and that their content will be disclosed publicly?

Mr. Hammond: My hon. Friend is right. That would be one way in which the Government could provide some reassurance about their intentions for NICE, but I say again that NICE, despite its rather overblown title, was conceived as a vehicle for assessing clinical and cost effectiveness, which was a sensible idea. However, what happens with that information afterwards might become dangerous. That is essentially a matter for the politicians and it is extremely important that we keep the distinction between what they decide and what information the


technical experts and advisers can bring to us, better to inform our debate about the way in which to use the limited resources available to the NHS.

Mr. Swayne: On the suggestion of the chairman of the national institute that it might have to recommend that a treatment is too expensive, the current situation is that many health authorities have made such a decision, which has given us the horror of treatment by post code. By transferring that responsibility to the national institute, we are in effect ensuring that such treatments will be available within no post code whatever.

Mr. Hammond: My hon. Friend is exactly right. The Government have said that they want to reduce regional disparities, but they are unable to put forward a convincing argument that the advice of NICE, properly implemented, will not inevitably mean a levelling down of services.
The Government have not said that they will make funds available—they have been given plenty of opportunities to give us that assurance—to enable best practice on every drug to be followed nationally as a result of the initiative to eliminate regional disparities. If the budget is not to be expanded, and if the service is to be increased in other areas, it is logical that the availability of some treatments will inevitably be reduced. The Government cannot have it both ways: they cannot eliminate regional disparities and also assure us that the purpose of their reforms is a levelling up of service.
I accept new clause 4 for what it is, and I think that NICE works well in that role. However, my criticism of new clause 4 is that it begs the question whether we should assess treatments, interventions or drugs that are available for a condition if there are no alternative treatments against which they can be appraised for clinical and cost effectiveness.
That brings us right back to the original question of how we are to make rational rationing decisions in the NHS, recognising the overall resource constraint. Beyond the role that new clause 4 would cast for NICE—that of assessing the relative clinical and cost effectiveness of different solutions to the same problem—we would need to debate the question of how we go about assessing which areas should or should not be prioritised if there is only one solution to a problem and it is very costly and there are a number of such problems and not enough resources to allow all the demands for treatment to be met. There may be many answers to that question, but the position is pretty clear to anyone who has considered the scale of the problem and the funding gap were there to be—as Ministers would like to believe—no rationing in the NHS. The problem could certainly not be solved with the product of 1p on income tax, which is the standard Liberal Democrat response to these difficult questions.
The technical input of NICE would be extremely welcome and useful in that debate if we could solve the political questions of how the total budget should be divided up and how we should deal with the overall resource limitations. If we had a good mechanism for doing that, it would presuppose that the Government recognised that there was an issue to be addressed. Politicians should not shunt decisions on to NICE. We must set the framework, and then let the experts deal with the technical questions.
I cannot be quite so complimentary about new clause 14. New clause 4 is worth while, but its provisions would be unravelled by new clause 14. The first two subsections are unexceptional. They require NICE to meet in public and to publish a report annually. Both themes were pursued in Committee, with the objective of making the processes by which difficult decisions are made more transparent and understandable to the public, who feel the impact of those decisions.
Subsection (3) of new clause 14 proposes:
The Secretary of State shall establish a public consultative committee in relation to the Authority, which shall have the duty of advising the Authority on the public's view on the priority to be accorded to different treatments and clinical interventions within the NHS.
I was disappointed to read that, because it goes against the grain of new clause 4, which would make NICE an objective and technical body that weighed up the clinical efficacy and cost effectiveness of treatments. Feeding the result of a public consultation exercise into NICE's decision-making process would be dangerous, because it would introduce an element of subjectivity that is properly the domain of politicians. It would be better for NICE to consider the relative cost and clinical effectiveness of various treatments and for another body to consult public opinion. Both those strands of information could feed into the political decision-making process. The Secretary of State must ultimately make the decisions.

Mr. Hayes: As well as compromising the empiricism of that professional body, might not the notion of public consultation that my hon. Friend describes be interpreted by the Government—but no one else—as an alternative to a proper, full and open public debate? Is not the proposal a sop to public consultation rather than the proper debate that should be taking place in the wider community and in this place about the key priorities that my hon. Friend identified earlier?

Mr. Hammond: My hon. Friend is right. We must never be trapped into believing that, because NICE exists and will examine the issues objectively, there is no need for a wider debate on the rationing of resources in the NHS.
The experience of public consultation in prioritising health care is not particularly happy. Most people who are interested in the subject will think immediately of the Oregon experiment. I suspect that none of us was impressed by the priorities that the public in Oregon gave for publicly funded health care. A straw poll of Members of Parliament would probably put cosmetic breast surgery a lot further down the list than the citizens of Oregon did. I caution the hon. Member for Oxford, West and Abingdon about the usefulness of a crude public consultation exercise.
New clauses 4 and 14 appear to contradict each other. New clause 4 rightly emphasises that NICE should stay out of the political debate, but new clause 14 would send it straight to centre stage.

Mr. Bercow: My hon. Friend is invariably courteous in exchanges in the House. Perhaps I can try to decipher what he is saying. Is he telling the House, in his


extraordinarily polite fashion, that the hon. Member for Oxford, West and Abingdon is guilty, in new clause 14, of vulgar and unworthy populism?

Mr. Hammond: I leave it to my hon. Friend to decide whether it is vulgar and unworthy. In fairness, the desire for public consultation at all stages and on all issues is almost a mantra with the hon. Member for Oxford, West and Abingdon. In some cases, we have disagreed with him because he has suggested taking that process too far. He has a genuine desire to have some public input into the debate and we believe that that will be required, but we also feel strongly that their input should not be to NICE but should run in parallel with its work and inform the political process.

Mr. Hayes: Is my hon. Friend saying that although the hon. Member for Oxford, West and Abingdon is implicitly unworthy by being a Liberal Democrat, he is personally incapable of vulgarity?

Mr. Hammond: I shall move on from that subject. I detect a certain muddle in the juxtaposition of new clauses 4 and 14. None the less, new clause 4 has served a useful purpose in allowing attention to be drawn to the gap between the role that the Government have consistently implied for NICE and the one that we fear may evolve, by design or by chance, and which its chairman has acknowledged will be a potential issue.
New clauses 16 and 17 deal with a separate issue that is another example of the working of the rationing agenda. The two new clauses, as the hon. Member for Oxford, West and Abingdon acknowledged, have been driven by the public debate over Viagra, which has raised awareness in the popular press and the public mind about some issues that might have remained obscure had they been discussed only in connection with beta interferon and the other drugs that were mentioned earlier.
By focusing the debate on Viagra, the popular press has moved forward the overall debate about rationing and the mechanisms by which rationing decisions are made. As has been mentioned, the courts have become involved in the debate about the availability of Viagra and have sent a message to the Secretary of State for Health about what he may and may not do in the exercise of his powers.
It is important for hon. Members who were not present in Committee and have not had the opportunity to consider the Bill in as much detail as the rest of us to set this issue in the context of wider concern among general practitioners about the undermining of their freedom to prescribe and threats to their independent status. As we move from GP fundholding to the new system of primary care groups and, ultimately, primary care trusts, it becomes important to maintain the confidence of GPs that the system will protect the important role that they play.
The Government have implicitly recognised the concerns and apprehensions of GPs. The first sign of that was when the former Minister of State wrote the now famous letter to the chairman of the general practitioners committee, and there have been various attempts since—not least by the Minister himself a few weeks ago—to reassure GPs about what the transition to primary care trusts would mean for them.
GPs have never before come up against such an explicit act of rationing as the Secretary of State implemented with his decisions on Viagra. He may have chosen Viagra deliberately as the ground on which to hold the debate, because it is not a drug which has a life-saving effect. However, I should say immediately that it deals with a condition that can be distressing and costs the NHS a lot of money to treat in other ways. If I did not say that, the hon. Member for Oxford, West and Abingdon would jump up and say it for me.
The Secretary of State has moved the debate on rationing forward another notch. A couple of weeks ago, Doctor magazine ran the headline "Rationing: it's official". The Secretary of State may not have used the word "rationing", but everyone in the medical profession knows that a Rubicon has been crossed. For the first time, he has proposed making a drug or treatment available to some people only, on a basis other than need. That is a significant change. It may not touch many lives as long as it is limited to Viagra, but we, and most commentators, would expect that, as other innovative drugs become available, the methodology tested with Viagra will be more and more widely employed.

Mr. Bercow: I am confused about the stances of different members of the Government. How does my hon. Friend reconcile—if it is possible—the stated position of the Secretary of State in respect of Viagra and the oft quoted remark of the Minister for Tourism, Film and Broadcasting that there would be more and better sex under Labour?

Mr. Hammond: rose—

Mr. Denham: He is embarrassed.

Mr. Hammond: I am somewhat at a loss. I thought that my hon. Friend was going to challenge me to reconcile the actions of the Secretary of State with the remarks of the Minister for Public Health; I am afraid that he has thrown me a little. I must confess that I cannot reconcile the Secretary of State's actions with that rather unwise promise.
This is a matter of significance and not merely something for the tabloid press to titter at. Until September 1998, when the Government introduced their interim guidance on Viagra, treatment for erectile dysfunction was fully funded throughout the NHS. The Government may have been panicked by media stories exaggerating the likely demand for Viagra when it became available in the United States; the Secretary of State has said that the stories were material considerations in formulating the policy. It has subsequently appeared that such stories were exaggerated both here and in the United States.
The Government issued interim guidance advising general practitioners that they should not prescribe Viagra other than in exceptional circumstances—which were not properly defined. The High Court recently found that guidance to be illegal on the grounds that it contravenes both the doctor's professional duty to treat his patient and the requirements of European Union law. You see, Mr. Deputy Speaker, that I was not being facetious when I mentioned Brussels earlier.
There have been attempts to suggest that erectile dysfunction is different—that it is somehow less worthy than other conditions and so automatically of lower


priority. However, the Secretary of State has admitted that it is a distressing condition, that it has serious medical consequences for sufferers and their partners and, interestingly, that 85 per cent. of cases result from underlying organic disease rather than from psychological problems.

9 pm

Mr. Fabricant: Does not my hon. Friend find it worrying that several Labour Members have said that the problem is a life style issue? Is not it far from being that?

Mr. Hammond: That is right, and some of the early scaremongering in the popular press focused on that. However, in fairness to the Secretary of State, he has made it clear that erectile dysfunction is a serious medical condition with serious consequences. Until recently, its treatment was fully funded under the national health service, but an arbitrary decision has been made to cease that funding for all patients. The result will be discrimination between groups of patients.
I suspect that the medical profession's outrage at the Secretary of State's decision to use schedule 11 to the 1992 regulations to limit the prescription of treatments for erectile dysfunction is what has caused the hon. Member for Oxford, West and Abingdon to take action. The British Medical Association said that the Secretary of State's action was arbitrary and that it would exclude people with genuine clinical need. It is important to recognise the significance of that: for the first time, official policy has acknowledged that people in genuine clinical need will be denied a treatment. That is a change in the ethos of the national health service, and deserves serious exploration.
New clauses 16 and 17 would make it impossible for the Secretary of State to resort to the mechanism that he has used previously to limit the availability of such a drug. If the Minister could bring himself to recognise the rationing that exists, he might say that the proposal from the hon. Member for Oxford, West and Abingdon is not the best way to deal with the matter. He might admit that a mechanism is needed to resolve the problem posed when a clinically effective but increasingly expensive drug is available for use but cannot be afforded within the national health service's resource constraints. Both I and my right hon. Friend the Member for Maidstone and The Weald has been saying that for the past year, but there cannot be a sensible debate until the Government acknowledge that rationing exists.
The real objection, which we share with many clinicians, is to the fact that the Government make rationing decisions on grounds of costs—and it is clear that the decision about the availability of Viagra is one such—but then try to justify them on pseudo-medical grounds that are quickly disowned by authoritative medical opinion. One of the important issues to flow from the recent decision is the question of discrimination in the NHS, a matter to which we shall come in a later debate. However, that discrimination will not be for reasons of gender, race, sexual orientation or age. People with a given condition will suffer discrimination based on how they came to have the condition.
That is equivalent to accident and emergency departments being asked to treat people with broken arms differently depending on whether the limb was broken in the course of work or leisure. Instinctively, we find that inappropriate, and new clauses 16 and 17 would make it impossible in the future.
The Government's approach to the treatment of male erectile dysfunction has shown the reality of the existence of rationing. There are, however, numerous examples of so-called post code rationing, when health authorities themselves have decided that they will or will not fund something. That is incompatible with the Government's expressed desire for universality in the NHS and their commitment that doctors should be free to treat patients according to clinical need. Given the resource constraints of the NHS, the Government must explain how they will square their desire to eliminate unjustifiable regional variations—a form of discrimination—with the lack of any significant additional resources to enable levelling up.
We would have been delighted if the Government had accompanied the introduction of the National Institute for Clinical Excellence with an announcement that it would provide a levelling-up process so that the best and most clinically effective practice would be made universally available. That would have been good news for many patients, but it would have raised questions of how the improvement would be paid for and how the wider debate over rationing would be dealt with.
Rationing is one of the most serious problems faced by the NHS, and the Government and Parliament, rather than institutions with powers and responsibilities devolved by the Secretary of State, must confront it. It is, and must remain, intrinsically a political issue. As new clause 4 implies, NICE must remain an advisory body, and Ministers must take the hard decisions.
Although new clause 4 usefully highlights the rationalisation potential of NICE and the Government's unwritten agenda of using it as a rationing device, it does not fully answer the problem of rationing. With the greatest respect to the hon. Member for Oxford, West and Abingdon, that is not compatible with new clause 14.
New clauses 16 and 17, by contrast, go to the heart of rationing, demanding a coherent response from the Government and something more than the mantra that rationing does not exist—a denial which does not move the debate a millimetre forward. Despite the Minister's consistent assurances that he is anxious to engage in constructive debate, the denial that rationing happens continues to prevent sensible debates that would benefit our constituents and the people of the UK. Instead, the Government have condemned themselves to continual stonewalling and have boxed themselves into an absurd position.

Mr. Bercow: I congratulate the hon. Member for Oxford, West and Abingdon (Dr. Harris) on the presentation of his argument. As my hon. Friend the hon. Member for Runnymede and Weybridge (Mr. Hammond) observed, there are flaws in his position and in that of his party. There is not a complete identity of view between the stance of the Liberal Democrats and that of the official Opposition. However, I respect the hon. Gentleman's medical experience, in spite of the occasional eccentricity of his political viewpoint. A good deal of the rationale behind his arguments will have commended itself to hon. Members and to people outside the House. In so far as it attempts to flush out the Government's position and to deny them the opportunity of continued obfuscation, it is welcome.
The contribution of my hon. Friend the Member for Runnymede and Weybridge was typically succinct. It was a remarkable performance for my hon. Friend to confine


his remarks to one hour in the interests of the progress of the debate. His lucidity and eloquence are such that we should have been happy to listen to a continued exposition of the arguments for considerably longer. I can only assume that his natural concern that others should get in on the debate caused him to relent and resume his seat.
At the heart of this debate and essential to any meaningful discussion of new clause 4, and certainly to discussion of new clauses 14, 16 and 17, is the concept of rationing. We come back to that central issue time and again.
Without giving him any advanced warning, I asked my hon. Friend the Member for Runnymede and Weybridge what he considered to be the difference between rationing and the prioritisation of resources, or at least the allocation of resources, within a finite budget. My hon. Friend legitimately chose not to answer directly. He cannot be expected to surmise exactly what Ministers are thinking. Much of the time their thoughts are impenetrable and their expression of whatever thoughts they have, still more so. It is not reasonable for my hon. Friend to be expected to decipher exactly what Ministers—in their statements or lack of them—intend us to infer. However, the Minister has the opportunity to tell us tonight his understanding of the difference.
For the avoidance of doubt, the challenge is simple. What is the difference between rationing and the prioritisation of the allocation of resources within a finite budget in the national health service? I cannot conceive of a way in which the question and the challenge could be more simply put. I appeal to the hon. Gentleman to answer that question tonight.
Also, I ask the Minister to confirm that he is content absolutely with the reply on rationing offered by his right hon. Friend the Minister for Public Health on 15 December 1998 at Health Question Time, which is in Hansard, column 746—it is important to be precise about these matters. My right hon. Friend the Member for Maidstone and The Weald (Miss Widdecombe) challenged the right hon. Lady as to whether there was rationing in the NHS. On that occasion, the Minister for Public Health looked like a rabbit caught in front of the headlights. I say that with no disrespect to the right hon. Lady. Her predicament was understandable. My right hon. Friend the Member for Maidstone and The Weald scares the living daylights out of me and she is my right hon. Friend, so it is perfectly imaginable that she would have caused terror in the heart and mind of the Minister for Public Health. Nevertheless, the right hon. Lady was obviously frit. She did not know what to say and thought that the shortest possible answer was probably the best escape route. She unwisely replied to the challenge of whether there was rationing in the NHS, "No." Moreover, she did not content herself with giving that answer once. Working on the assumption, I think, that having said it once it was best to stick to it and say it as many times as necessary, she repeated that answer on two further occasions in response to challenges from my right hon. Friend.
That begs the question that if there is not rationing in the NHS, what does the Minister believe is happening daily in our health service when, because of a lack of funds, the availability of treatment is limited and people are either denied it altogether because of the absence of

funds or are told that they will have to wait longer than they otherwise would for that treatment, until further funds are available? If that is not rationing, the Minister must explain the intellectual distinction between rationing, which he disavows and claims is not occurring, and the denial of treatment because of an insufficiency of resources, which he cannot disavow and that he knows is occurring.
9.15 pm
I am sure that the Minister will be interested to hear the official definition. I have taken the trouble to find out that, on page 2482 of "The New Shorter Oxford English Dictionary"—copies of which are available for consultation in the Library during the drier parts of my speech—the verb "to ration" is defined as follows:
to limit to a fixed allowance.
The dictionary helpfully continues with another definition of the verb:
to share out in fixed quantities.
I am grateful to my hon. Friend the Member for Boston and Skegness (Sir R. Body) for suggesting that ratios are involved in this matter. To ration implies the existence of ratios. I hope that, at least on that point, there can be unanimity among the parties in the Chamber. Does the Minister accept those meanings of the word "ration", or is this new Labour Government so arrogant that they believe that they know the definition of words better than the distinguished sources who compiled the "New Shorter Oxford English Dictionary". We know not. Perhaps we shall be told. I hope that we shall hear about that before the conclusion of the debate.

Mr. Swayne: Is not the attitude and the new-speak of the Labour Government made manifest in the Bill by NICE, CHIMP and PRODIGY?

Mr. Bercow: I am grateful to my hon. Friend for making that point. In previous reflections on these matters, I have challenged the Government as to the profusion of those new bodies and the peculiarly inelegant titles that Ministers have conferred on them. Indeed, on one occasion I regarded it as a particular pleasure to reel off no fewer than six such bodies during a question to the former Minister of State at the Department of Health, the right hon. Member for Darlington (Mr. Milburn), now the Chief Secretary to the Treasury. I should like to trouble my hon. Friend for further details, but fear that I should try your patience, Mr. Deputy Speaker, if I did so tonight.
I should be happy to give way to the Minister at any point in my remarks, if he feels inclined to answer this central question: if there is no rationing, what is happening now? If there is no rationing, why does almost everyone in the United Kingdom—intelligent, unintelligent or of varying degrees of intelligence—believe that there is? Why is it that the Government are right about this question, even though they are in a tiny minority and are disbelieved, but that everyone else is wrong?

Sir Richard Body: Surely, the origin of rationing was to give to five people what was normally available for four—hence the word "ratio". In relation to the health service, in most of our


constituencies, although five people are lining up for operations, there is time to carry out only four operations. Resources are available only for four operations, but five people want an operation.

Mr. Bercow: Rationing can take a variety of different forms. It is not in dispute that, because of the constraint of insufficient resources, if people cannot receive treatment, or cannot receive it until a certain period has elapsed, that constitutes a form of rationing. My hon. Friend is right to describe another form of rationing, but if people cannot have treatment now because there is no money to pay for it—or there is money to pay for treatment for only four people, rather than for five—manifestly, in ordinary, everyday parlance, we must conclude that that constitutes a rationing of the available treatment.
I hope that the Minister will agree with that. I look to him, with beads of sweat upon my brow, in eager anticipation of a straightforward answer to a straightforward challenge. He sits there, he cogitates, he looks down at his notes—

Mr. Brady: He sweats.

Mr. Bercow: I am not in a position to confirm the accuracy or otherwise of that observation. I simply ask the Minister to confirm that he accepts—so far, because I want to take him step by step through this issue—the validity of what I have said. Does he accept the definition of rationing that I have given?

Mr. Deputy Speaker (Mr. Michael Lord): Order. I am sure the House will agree that we have now dealt adequately with the definition of rationing. Perhaps the hon. Gentleman will now move on.

Mr. Bercow: I am happy always to be guided by you, Mr. Deputy Speaker. Although I immediately accept your ruling that we have adequately debated the definition of rationing for tonight and that to avoid tedious repetition and defiance of the rules of order we cannot continue to have that debate on this occasion, there will be ample opportunities in the course of this Parliament for debate to be rejoined.
I say to the Minister of State in the friendliest spirit, he should not imagine that he can get away with avoiding an answer to my question tonight, because we shall be back. We shall be back before breakfast, before lunch, before tea, before dinner and before we consume the bedtime Ovaltine to harangue him on this issue. He knows that all of those present in the Chamber are assiduous attenders of parliamentary debate, as is my hon. Friend the Member for Boston and Skegness, and we shall pursue the issue at every opportunity.
New clause 4, moved by the hon. Member for Oxford, West and Abingdon, specifies that clinical efficacy or relative cost effectiveness should be the criterion on which treatments are prescribed. He suggests that overall cost or the possibility of additional cost to the NHS should, of itself, not be a criterion. However, I agree with my hon. Friend the Member for Runnymede and Weybridge that there have to be limits to total expenditure. We would argue an absurdity if we were to suggest that there could be limitless expenditure.
I have reflected carefully on this issue. I have reflected carefully on the unpopularity of rationing: it is almost the inadmissible sin of the operation of the NHS. It is to the great credit of my hon. Friend the Member for Runnymede and Weybridge and my right hon. Friend the Member for Maidstone and The Weald that they have tried to cut the Gordian knot of that debate. They acknowledge that there are, of course, limitations of resources within which judgments have to be made, but that ordinarily clinical judgments should be respected and once there is a budget known, Ministers should not retreat into arguments about resources when to do so negates the power and clinical freedom of, for example, in the field of multiple sclerosis, neurologists.
The hon. Member for Oxford, West and Abingdon referred to the debate about beta interferon. He and I are currently engaged in a correspondence on this important matter, and I know that hon. Members on both sides of the House with genuine concern about multiple sclerosis sufferers have raised with Ministers the question of the funding of beta interferon and its continuing provision.
My concern is that the Government are not being up front and saying that resources are of the essence and that it is a lack of resources that is causing them to think about ways in which to restrict the availability of the drug. Even though to make that admission would give rise to some hostility and considerable debate, the admission would be honest. I would go so far as to wager—and I believe that my right hon. Friend the Member for Maidstone and The Weald would concur with me on this—that the Government would win respect for candour and openness. In respect of beta interferon, it is their pretence that factors other than limitations on resources are uppermost in their minds that leads sufferers from that chronic neurological disease to distrust them.
I would go so far as to say that there are some who despise the attitude of the Government because it is not frank, candid or open. The Government treat the people of this country and the sufferers of the disease who know about it and feel it in a way that none of us can emulate as stupid: they simply consider that they cannot grasp the issue. That is unfair.
Let us take the particular case of the provision of beta interferon to sufferers of multiple sclerosis. The House will be aware that there are four forms of multiple sclerosis, of which the two most commonly debated in the Chamber are the relapsing-remitting and the secondary progressive forms of the disease. There is a limited number of manufacturers of the drug beta interferon, of which perhaps the most notable is Schering Health Care plc. It currently supplies beta interferon to those who suffer from the relapsing-remitting form of the disease, but it has recently been granted a licence—I believe I am correct in saying that it is currently the only manufacturer to have been granted such a licence—to supply that version of the product that treats the secondary progressive form of the disease.
Ministers have acknowledged that there has been some testing of the efficacy of the drug, but, either deliberately or inadvertently, they have sought to convey an impression of ambiguity. The Minister will acknowledge that he does not have medical expertise—if I am mistaken, he can correct me. I am not trying to score a point against the hon. Gentleman because I do not have medical expertise either. However, consultant neurologists have such expertise, as do those who undertake the trials of this


drug, and of others. I hope that the Minister will accept—I have made this point before—that there have been so far no fewer than four independent and separate trials of the clinical effectiveness of beta interferon. I shall come to the question of cost in due course.
I suggest that those separate, independent trials have proved conclusive. They have shown—the Minister acknowledged this recently in reply to an Adjournment debate introduced by me on 14 May this year—that treatment for the relapsing-remitting form of multiple sclerosis with beta interferon can reduce the rate of relapse by up to 30 per cent. as well as the severity of the relapses. Treatment with the drug over a period of three years can reduce the speed of deterioration in the condition by up to one year.

Mr. Fabricant: I am sure that my hon. Friend would not want the House to think that it is only beta interferon that the Government claim has clinical deficiencies. Is my hon. Friend aware that the Government also claim that Taxol, an excellent drug used in the treatment of certain cancers and in the reduction of certain malignant tumours, should be restricted not because of its cost but because of its efficacy? However, clinical oncologists argue that Taxol is an effective means of treating certain forms of cancer.

Mr. Bercow: I am grateful to my hon. Friend. I was not aware of that point. My hon. Friend has now enlightened me and, in so doing, he underlines the fact testified to by my hon. Friend the Member for Runnymede and Weybridge that this problem applies across the board.
If there were just one disease to which the Government's rather curious attitude applied, our argument might not be conclusive. It is a fact that for many diseases there is a drug that clinicians believe will be effective but over which Ministers hesitate, and that is a serious problem. Ministers claim that their decisions are based on the fact that the efficacy of the drug is unproven. We suspect, and patients are convinced, that a reluctance to fund is at the root of the Government's constant prevarication.

Mr. Fabricant: Would my hon. Friend care to speculate that the Government would earn respect not only among parliamentarians but among those in the medical profession if they came clean and said, "Yes, there is rationing. That is not surprising. There ought to be rationing because, whether we like it or not, there are limited resources. Given that there is rationing, let us approach the problem logistically, logically and systematically and try to find a solution"? The fact that they deny that rationing takes place and that they try to deceive the electorate and patients means that they earn the disrespect of this House and those who know that the NHS is not safe in Labour's hands.

Mr. Bercow: I agree entirely with my hon. Friend. That lack of candour applies across the board. I appeal to the Minister to abandon his nescience and to admit that the Government are trying to present the issue in a way that

clouds the facts instead of clarifying them. [Interruption.] I am sorry if the Minister is uncertain about the word "nescience". The late parliamentarian of 37 years' standing, the right hon. Member for Down, South—and, before that, the Member for Wolverhampton, South-West—once said to the Member for Harrow, East, who was so unwise as to claim that Mr. Powell had used a word that did not exist, that if, during the drier parts of his speech, the hon. Gentleman would like to avail himself of a copy of the Oxford English Dictionary in the Members' Library, he might look up the word "transfretation", and he would find it all right. I say to the Minister that if he looks up "nescience" in the dictionary, he will certainly find it. I shall not help him because he should learn by discovery and the effort required to consult the dictionary. He will benefit from that.
The Minister acknowledges that there is a patchwork of provision of beta interferon throughout the country. That point is common ground between us. In the debate on 14 May, he reiterated what he had said at health questions some 10 days earlier. He said that there are great disparities between what health authorities in different parts of the country provide. We agree on that.
Dr. Dennis Briley, consultant neurologist at Stoke Mandeville hospital, which serves many thousands of my constituents, has described that situation as treatment by postcode. He disapproves of that, I disapprove of it and the Opposition disapprove of it. The Minister of State implies that he disapproves of it and contends that the Government's proposals for the National Institute for Clinical Excellence will lead to increasing provision and greater equality of provision throughout the country. I am not sure that their proposals will deliver anything of the sort because I subscribe to the view of my hon. Friend the Member for Runnymede and Weybridge that NICE is being set up in a way that will give the Government an excuse to ration while avoiding the blame for its effects. They intend NICE to carry the can.
I am concerned, and my concern is reinforced because the Minister of State has on several occasions given a bogus reason for the disparities in treatment. I will not accuse him of bad faith.
By the standards of a Labour Minister, and at the risk of causing grave embarrassment and damage to his future, I shall go so far as to say that I have always thought the hon. Gentleman the closest approximation to a normal human being on the Government Benches whom I have encountered since 1 May 1997. I do not think that he is advancing such a reason deliberately. I think that he genuinely believes that difference of opinion among consultant neurologists is the reason for the disparity in provision of beta interferon across the country.
On 4 May, in answer to a question from me, the Minister suggested that differences of opinion among consultant neurologists explained the variations in the amount of treatment provided by different health authorities.

Mr. Denham: I am grateful for the hon. Gentleman giving way on this very important point. I believe that the record will show that I indicated that it was one of the factors that influenced the differences in prescribing.


To my recollection, I certainly did not indicate that it was the only explanation of differences in prescribing policy in different parts of the country.

Mr. Bercow: I am grateful for that assurance. The Minister is edging his way towards a more satisfactory position. He will forgive me for saying so, but when he made that point before, he did so with some emphasis. The impression which many of us gained, including my constituents who suffer from the relapsing, remitting form of multiple sclerosis, was that he was taking refuge behind clinical differences of opinion. I do not say that unkindly to the Minister, but my constituents, Caroline Cripps, who is 28 years old and from Westcott, and 31-year-old Mr. Marc Smith from Buckingham, both believed that the Minister was trying to use that point as an excuse for the variations in provision. If he is assuring me now that it is but one of the factors and that it is by no means the major factor, I am very grateful. The debate has already advanced if he is prepared to make that admission.
I should like to take the debate a stage further. If the Minister is to advance difference of opinion among consultant neurologists as an explanation—not necessarily a justification—for the disparities in treatment, he is duty bound to consider the position when no such disagreement exists, but, rather unanimity of view.
I cannot expect the Minister, much as I would like him to do so, to recall word for word the exchanges between us during an Adjournment debate on 14 May. He may recall that I reminded him of the position in the south-west of England, where all 18 consultant neurologists had decided that the provision of beta interferon for particular multiple sclerosis sufferers would be clinically effective. Despite that unanimity of view, such treatment was for long periods not made available. Therefore, it is simply not good enough for the Minister to talk about differences of opinion as an explanation for the provision of treatment.
When there is unanimity of view among the people whom we all accept are the experts, and still the funding is not made available, we must conclude that other factors are at work. Either a political decision has been made or financial factors explain the unwillingness to fund.

Mr. Swayne: Is not the very purpose of new clause 4 to ensure that the national institute takes a considered view on the basis of positive science as to the efficacy of a treatment such as beta interferon? The danger, as evidenced by the statements of the chairman of the national institute, is that NICE may well decide that such treatment should not be available simply on the ground of cost.

Mr. Bercow: That possibility does exist. I am sure that my hon. Friend will agree that it emphasises the importance of having the maximum discussion in public of what the priorities should be, the criteria upon which judgments are made, and the mechanisms to review those judgments.
There is no shame, even for a commission, in making an honest mistake. There is only shame in failing to acknowledge the possibility of having done so. It is precisely because we can get it wrong from time to time, and clinicians can make mistakes, that there must be review mechanisms. The magnifying glass of publicity,

which the hon. Member for Oxford, West and Abingdon mentioned in different terms, is important in that process. The more private discussion and confidentiality there is, the less confidence there will be. The more public discussion and openness there is, the greater confidence there will be in the propriety of the decision-making process.

Mr. Brady: Does my hon. Friend agree that it is a matter of concern that, in the pursuit of cost saving through the activities of the National Institute for Clinical Excellence, there may be a reduction in communities' ability to have an input into the priorities for health care, and that, in pursuing uniformity, NICE may be the enemy of good provision because, at the moment, some communities may set different priorities from others?

Mr. Bercow: There is a respectable argument for the view that my hon. Friend is expressing. I think that, essentially, his thesis is that, if there is competition and local flexibility, the best will tend to drive out the worst, or, at least, that the better will tend to drive out the worse. Is that what he is suggesting?

Mr. Brady: That would tend to be the case, but, more fundamentally, it is appropriate for local communities to have some input into the decision-making process, and for a health authority to be able to set priorities different from those of a neighbouring health authority if the population that it serves wishes.

Mr. Bercow: There is an argument for that. However, it is important that, if such arrangements are to be instituted, the forum in which such decisions are taken does not become dominated by the activist who is willing to attend most regularly. There must be a check on the idea that, simply by packing a particular meeting, for example, one view can hold sway, even if the validity of that view turns out, on later inspection, to be outweighed by that of another. I am not averse to what my hon. Friend is suggesting, but I think that we could get into difficulty unless we very carefully consider the constraints within which such local discretion is operated.

Mr. Swayne: Will my hon. Friend bring his precise use of language and analysis to bear on the problem in the way that I suggest it is defined now? The easy bit is to decide, on the basis of positive science, whether a treatment is clinically effective. The question whether it can be afforded is a normative question, requiring a normative judgment, and our difficulty is finding the forum in which that normative judgment can be made. In putting together the Bill, the Government have run those two functions together into NICE, and it is entirely inappropriate for that one body to try to fulfil both the positive and the normative role.

Mr. Bercow: My hon. Friend makes a powerful point. There is no sense in which we can honestly say that a specific treatment cannot be afforded. In fact, although we might not realise it, it constitutes bad faith so to argue. In practice, the Government do not go bankrupt any more than local authorities, the creations of statute, do, so it follows that, in the final analysis, the judgment is about whether we want to afford a specific treatment or whether we prefer resources to be directed to the provision of an


alternative treatment for the same condition or for an entirely different one. Therefore, I accept the thrust of what my hon. Friend is saying.
9.45 pm
I have spoken about a situation in which there is unanimity of clinical judgment that is ignored or, worse, scorned by administrators or politicians. However, the argument can be taken a stage further. I have made the point to the Minister before. I do not recall that he had an effective response to it, which rather suggests to me that he did not. If he had, I think that I would remember it. I do not, so I do not think that he possessed such an answer.
What about a situation in which there is no unanimity of view, but individual clinicians are advising what they think is right for their particular patients? In the debate on 14 May, in which I raised the problems of multiple sclerosis sufferers in Buckinghamshire, the Minister said quite reasonably to me and to the House that he recalled that the four neurologists in Buckinghamshire who were consulted about the efficacy of beta interferon disagreed. He said that given the difference of opinion among the four consultants, it was not surprising that a decision to fund on a significant scale by the Buckinghamshire health authority had not yet been made.
I see the hon. Gentleman's point, but I hope that he will not use the fact of differences of opinion among respected consultant neurologists as a justification for the denial of funding. In short, just because one neurologist does not think that the treatment is generally effective, or concludes from his analysis that it would not be efficacious for his particular patient, that does not mean that it should be denied to others.
If another neurologist, readily accepting the drug's inappropriateness for other patients, said, "Ah, yes, I accept that, Minister, but beta interferon will be efficacious for my patient", does the hon. Gentleman accept that that judgment should be respected? Does he agree with the proposition that where the neurologist judges that the provision of beta interferon will be clinically effective, it should ordinarily be prescribed? The hon. Gentleman does not answer. He is mute. The position is fixed. The head does not move. There is no flicker of emotion or indication of stance from the hon. Gentleman. I shall wait patiently for his winding-up speech.
I have on previous occasions worried that at a late hour, Ministers might inadvertently neglect to respond to the points that my hon. Friends have made.

Mr. Eric Forth: No. Surely not.

Mr. Bercow: My right hon. Friend cavils at the suggestion that a Minister might inadvertently fail to respond to a point. I have the highest regard and affection for my right hon. Friend. Not every hon. Member or every current Minister can match his high standards. Just because he has instant recall, never forgets a point that is put to him, and is unfailingly effective and courteous in his response to any challenge, does not mean that he can demand or expect the same high standards of members of the new Government. My right hon. Friend had a number of years experience—[Interruption.]
My right hon. and learned Friend the Member for Sleaford and North Hykeham (Mr. Hogg) says from a sedentary position that my right hon. Friend the Member for Bromley and Chislehurst (Mr. Forth) may expect such high standards. He might expect them, as my right hon. and learned Friend points out, but he assuredly will not get them. It is possible that Ministers will neglect to respond to particular points.
I challenge the Minister, when he replies to the debate, to give me an answer to this question: does he agree that where a consultant neurologist believes that the provision of a treatment is clinically appropriate, it should ordinarily be prescribed? If he does agree, the hon. Gentleman will have made an important admission. The fact of differences of opinion does not mean that the judgment of an individual consultant neurologist in respect of a particular patient at a given time, possibly for a limited period, should not be respected. Rather, it tends to imply that that judgment should be respected and translated into practice.
I challenged the Minister on 14 May to make it clear beyond peradventure that the period between now and the issue of new guidance by NICE should on no account be used by any health authority to justify the reduction, still less the withdrawal, of funding of beta interferon. That goes to the heart of the issues raised by the hon. Member for Oxford, West and Abingdon.
I believe that the Minister gave a categorical assurance on that point, saying that until the new guidance comes forward the November 1995 guidance in the Government's circular should be honoured. I was grateful for that. So we assume that, for the time being, on the basis of a judgment about clinical effectiveness, neurologists should be free to prescribe and the drug should be available.
We now come to the question of the National Institute for Clinical Excellence and how it will operate. I should like to think that the institute will be absolutely independent, free to make judgments about clinical appropriateness and not subject to public or private pressure of any sort from Ministers or officials in the Department of Health.
It was because I wished to establish the status of NICE and the freedom that it would have to make recommendations and to issue guidance that I challenged the Minister on this point on 14 May. I asked whether NICE would be genuinely independent. I was not encouraged by the hon. Gentleman's reply. He told me that NICE would operate on the basis of a framework agreement with the Department.
I am a new Member and, on the whole, I am inclined to give people the benefit of the doubt. I have not yet been afflicted by the world-weary cynicism that characterises my right hon. Friend the Member for Bromley and Chislehurst. However, I smelt a rat. I detected a desire by Ministers to ensure that the institute would not be fully independent. I did not like the talk of a framework agreement. It seemed to me that the Department of Health would be saying to the institute, "You will volunteer to agree with the Government", with the proverbial gun being held to its head.

Mr. Forth: Will my hon. Friend give way?

Mr. Bercow: I shall readily give way to my right hon. Friend, who is wearing a particularly fetching tie.

Mr. Forth: If a word from the very old to the very new would be helpful, may I point out to my hon. Friend—he seems uncharacteristically to have missed this opportunity—that any Minister must have regard to the financial aspects of his policies? Therefore, it must be inevitable that real financial constraints must be placed on the policy that we are discussing from the outset. My hon. Friend seems to be suggesting that "framework" is being used to disguise real financial constraints, which will inevitably operate on the apparent clinical neutrality of the new organisation.

Mr. Bercow: This evening, there have been competing attractions. There has been the opportunity to enjoy a congenial dinner. There has been the option, which I admit is much the lesser of the two, of listening to my oration. My right hon. Friend was absent during the earlier part of my speech in which I said that it would be welcome if the Government would be candid, if they would say, "Yes, financial factors are at stake. Monetary judgments have to be made. There is not enough money and we cannot afford everything. We shall restrict the supply of some treatments because of cost limitations."
I pay tribute to the candour of my right hon. Friend the Member for Maidstone and The Weald and my hon. Friend the Member for Runnymede and Weybridge. They have acknowledged the existence of rationing and they are not afraid of it. They are principled conviction politicians. They are not scurrying around and retreating into the dark, afraid to admit the inevitable. The great British public are not stupid. They know that there is not a bottomless pit. They know also that there is a limit to what the public purse can afford. They know that judgments about what can be managed have to be made. It is a case of demand always exceeding supply. With a service that is free at the point of consumption, that will always be the position.
So, my right hon. Friend the Member for Bromley and Chislehurst is right: if Ministers would only say that there will be financial restrictions on what NICE can do, we would know that they were being honest. They could say, "The chairman of the institute takes one view. We, who have to apply the cash limits throughout the public sector, take another. We will insist that our view holds sway and the chairman of NICE will be shown the door if he does not like it." However, they are simply not prepared to do that.
Ministers want to give the impression that an independent body will make the judgments. If that independent body—knowing of the framework agreement and of the limitation on resources—declines to provide a particular treatment or reduces the quantity of that treatment in a given year, Ministers will retreat behind the fiction that that is an independent judgment decided by the national institute. Why do not they say, "There is a lack of funds. We politicians have to balance the books and we are restricting the freedom of NICE to do as it wishes"? As my right hon. Friend the Member for Bromley and Chislehurst said, there is nothing dishonourable in imposing some constraints on the freedom of NICE, but there is something dishonourable about denying the intention to do so.

Mr. Forth: Perhaps I can help my hon. Friend. Is it not at least possible that, in framing the terms of reference for that body, the Government could arrive at some compromise in which they would charge it with investigating clinical excellence while having regard to the

availability of resources? Perhaps they could use another term of art, something with which we are all too familiar. Does he accept that that would at least be a way forward for the Government, even though it would effectively reduce the independence of the body that is being set up?

Mr. Bercow: That would reduce the independence of the body that is being set up and it would of course entail an acknowledgement by the Government that they hold the purse strings.
The absurdity of the present position is that, although we all know that Governments fund the NHS, Ministers would like to give the impression that responsibility for funding will in future lie with NICE. We know that to be a monstrous fiction; it is such an absurd proposition that, as the late and great parliamentarian Enoch Powell would have said, only an extraordinarily clever person could fail to see the point.

Mr. Brady: I fear that, for once, my hon. Friend is missing the point. The Government do not want NICE to be seen as controlling funding. They want to be seen as providing funding, but they want NICE to be seen as restricting the treatments available.

Mr. Bercow: That would be a tortuous position for the Government to adopt. I do not rule out the possibility that that is what lurks in the inner recesses of what passes for the mind of a Minister in the new Labour Administration, but that does not make it a satisfactory position. Such a position is wholly unacceptable—it is dishonourable, it lacks candour and it flatters to deceive.
The hon. Member for Oxford, West and Abingdon, in addition to a number of other important points that he flagged up in this brief debate, raised the issue of the appraisal of treatments. [Interruption.] We are delighted at this stage of our proceedings to be joined by the right hon. Member for Holborn and St. Pancras (Mr. Dobson)—the Secretary of State for Health himself. As Lord Archer of Weston-super-Mare, when Member of Parliament for Louth, said to Prime Minister Harold Wilson, "Good of him to drop in."
We are delighted to see the right hon. Gentleman, but it is a pity that he has not attended the debate. I would like to say that it has been left in good hands, but I fear that that would not be correct. The Minister is a genial fellow, but he is finding it all a bit too much to take. We do not know whether a response from his lips will be forthcoming, but I hope that he will confirm in the short time that remains that the appraisal of the efficacy of a treatment will consider not only clinical costs, which have been referred to, but the wider costs entailed such as loss of tax revenues because of unemployment and help with adaptations to the home—for sufferers from extreme conditions such as multiple sclerosis, for example. All those factors must be considered in the equation and I would welcome an unequivocal assurance from the Minister that they will always be taken into account.
This is a debate of the utmost importance. Before the Bill creeps on to the statute book, we need to know what Ministers really intend for NICE.

It being Ten o'clock, the debate stood adjourned.

Debate to be resumed tomorrow.

Business of the House

10 pm

The President of the Council and Leader of the House of Commons (Mrs. Margaret Beckett): With permission, I should like to make a short business statement. The business for tomorrow will now be the consideration of a timetable motion relating to the Health Bill and to the Immigration and Asylum Bill, which will be followed by the conclusion of the remaining stages of the Health Bill and progress on the remaining stages of the Immigration and Asylum Bill. The remaining stages of the Immigration and Asylum Bill will be brought to a conclusion on Wednesday as previously announced.

Sir George Young: When the right hon. Lady announced this week's business only last Thursday, there was no mention of a timetable motion on either the Health Bill or the Immigration and Asylum Bill. The House will want to ask her what has happened between last Thursday and today to precipitate these announcements if it is not the Government's disastrous performance in the European elections. Will the right hon. Lady tell the House how many hours of debate she proposes for these two Bills? With regard to the Health Bill, we note that the Secretary of State for Health did not appear until a few minutes ago and had not attended the debate for the past few hours.
Is not the Immigration and Asylum Bill being guillotined to curb criticism from the Government's own supporters on the Labour Benches—criticism of a Bill that has few friends outside the House? Is that not further evidence of a Government who lost votes over the weekend and are now losing their nerve?

Mrs. Beckett: The right hon. Gentleman says that I announced this business only last Thursday, and that is true, but that was the third occasion on which I had announced that a full day's debate would be held on the Health Bill, and on none of those occasions did the Opposition say that there was any difficulty with that. I announced this business on 20 May, 26 May and last Thursday.
I am grateful to the right hon. Gentleman for asking me what has happened between then and now. I draw his attention to two things. First, the Opposition were offered a programme motion for the Health Bill to ensure that it was adequately debated in the time allowed, and for the remaining stages of the Immigration and Asylum Bill, but that opportunity was rejected for both pieces of legislation.
Secondly, this afternoon the House has spent three hours debating new clause 18, which relates to a relatively minor, technical and uncontroversial matter, about which the Opposition parties were forewarned in Committee in a letter from the Minister of State, my hon. Friend the Member for Southampton, Itchen (Mr. Denham). It was so uncontroversial that they did not even vote on it. If we were to continue at that pace, it would take us until the end of the week to conclude proceedings on the Health Bill alone, and that does not seem to us to be reasonable. If we are to allow time tomorrow to conclude proceedings on the Health Bill, which is only right, that will have an

impact on the two days that I had announced for the remaining stages of the Immigration and Asylum Bill, so that is the reason for this motion.

Mr. Paul Tyler: Will the Leader of the House confirm that there have been 85 Government amendments and new clauses to the Health Bill? Will she also confirm that the Bill was extensively discussed in the other place, so the late arrival of those amendments and new clauses is unacceptable. Will she give us further information on precisely what discussions have taken place with members of the Conservative Front Bench on an agreed programme motion? Was that proposal turned down on principle, or were the details of the programme motion that the Government proposed to put before the House unacceptable to the Conservatives? Do the Government accept that both Bills are very important, excite great public interest and attention and deserve much more careful attention in the House on a proper programme motion? A guillotine motion is certainly not the best way. It is a sledgehammer to achieve nothing.

Mrs. Beckett: I do not dispute the hon. Gentleman's last point. The Government would have much preferred to have a sensible programme motion. We have been driven to fall back on the guillotine because that was not possible. The hon. Gentleman is right to say that the Bill has already been extensively debated. It had 42 hours in the House of Lords and 77½ hours in Committee. The hon. Gentleman is also right to say that there are a large number of amendments. Most of them are minor and technical. Indeed, most were asked for during earlier consideration. Finally, the hon. Gentleman asked whether it was on a matter of detail or on principle that the Conservatives rejected a programme motion. We never got as far as details. The hon. Gentleman will understand why the Government have found it necessary to propose a guillotine motion.

Mr. Peter Luff (Mid-Worcestershire): Will the Leader of the House acknowledge that in the past three weeks we have had one week of recess and two weeks of exceptionally light business by any standards? If she had had the decency to give the House a reasonable amount of time to debate the Bill, the difficulties that we have had tonight would not have arisen. Does she understand that many of us feel that the three weeks of light business were intended to give Labour Members time to campaign in the European elections, and much good it did them? Their arguments were rejected by the voters. Does she understand that her running shy tonight of a proper debate on the Health Bill shows that the Government are fearful of having the arguments on the Bill properly tested in the House of Commons?

Mrs. Beckett: First, the hon. Gentleman's points about the previous business and the recess are irrelevant. If there was a problem with the time allowed for the Bill, it could have been raised on the past three occasions when I announced the time available. It was never raised by the hon. Gentleman or anyone else. The Bills could not have been considered earlier, because they have both just come out of Committee. I do not think that the hon. Gentleman has been in the Chamber this evening. If he had—I beg


his pardon if he has—he would have known that people have been wasting time and the House of Commons does not have time to waste.

Mr. John Hayes: Given the right hon. Lady's difficulties over the past week or so, particularly since Sunday, and her problems with ordering the business of the House effectively, which are clearly becoming profound, will she make time for an early statement on the Government's position on proportional representation for this House?

Madam Speaker: Order. That is totally irrelevant to the statement that has just been made.

Mr. Eric Forth: Is the Leader of the House bringing the same deft management to organising the business of the House that she brought to organising the Labour party's strategy for the recent elections? If so, will she answer the question put to her by my hon. Friend the Member for Mid-Worcestershire (Mr. Luff) and explain why the Government were prepared to mark time in the House of Commons for the past two or three weeks, but are now trying in indecent haste to ram through controversial and difficult business? Why cannot the Government face up to difficult issues and give the House of Commons a proper amount of time to deal with them instead of scurrying around trying to hide the difficult issues while wasting time in the lead-up to what was a disastrous election for them?

Mrs. Beckett: I do not think that the right hon. Gentleman can have been listening or paying attention. I have already said that the Government were prepared to discuss a programme motion for both Bills. The right hon. Gentleman always attends business questions. I pay tribute to him for being an assiduous attender. Not once has he or any Conservative Member said that the time allowed for debate on the Health Bill was inadequate. It is too late to say it now.

Mr. Ian Bruce: Will we have an opportunity during the debate on the Health Bill to talk about the £21 billion that the Prime Minister keeps talking about? The Leader of the House may have noticed that, for some reason, it was claimed as a great plus for Labour's candidates during the European elections. Will she confirm that that £21 billion is only £3.5 billion extra a year: £3.5 billion in the first year; £7 billion in the second year; £10.5 billion in the third year? We have to add them together to get £21 billion. Surely the country has found out about the Government's health policies and we need plenty of time to highlight what is going on.

Mrs. Beckett: I am sorry to say to the hon. Gentleman that no matter how much time we have, the Opposition are incapable of doing anything sensible with it, judging by their performance this evening.

Dr. Evan Harris: While I regret that the Leader of the House has had to make this statement, does she agree that part of the explanation for the behaviour of the increasingly extremist Conservative party is the fact that it has failed to provide opposition on the Immigration and Asylum Bill or on the Health Bill? On the issues of junior doctors' hours, rationing,

discrimination and the work force crisis, it was Liberal Democrat amendments that would have been discussed tonight before the Tories' futile behaviour intervened.

Mrs. Beckett: I do not think that it is for me to intervene in a private fight on the other side of the House, but I share the hon. Gentleman's view that we have not spent time discussing the Bill this evening.

Mr. Douglas Hogg: The right hon. Lady will know that, as Leader of the House, she has a role to take into account the interests of the House as a whole and not exclusively those of colleagues on her own Front Bench. Does she understand the concern felt by Conservative Members that what she has just announced may substantially reduce the overall time available for the debate on the Immigration and Asylum Bill? Can she give the House a guarantee that there will be no reduction in the time available for that debate?

Mrs. Beckett: The right hon. and learned Gentleman is right to say that I have a responsibility to the House. My responsibility is to see that the House has the opportunity sensibly and properly to debate the issues that come before it. It is not my responsibility to find time for time wasting.

Mr. Desmond Swayne: The Leader of the House will know from her experience of running a campaign over the past three weeks, during which she attempted to deal with every other issue than those that were the proper subject of that campaign, that it is on the issue of her stewardship of the health service that the public estimation of the Labour Government has fallen most rapidly. There was no complaint about the lack of time available for debate because there was plenty of time available. I and many other Conservative Members were looking forward to exploring the Government's attitude on rationing throughout the night. Why is the Leader of the House not prepared to do that? Is she tired or just frightened?

Mrs. Beckett: I fear that I have already pointed out that at the rate of progress achieved so far it would have taken to the end of the week to conclude proceedings on the Bill and I did not feel that that was a useful expenditure of the time of the House.

Mr. John Bercow: Does not the Leader of the House recognise that she is guilty of ignorance and uncharacteristic discourtesy to the House in describing the new clauses and amendments as minor and technical? Does the right hon. Lady seriously think that the issues of clinical freedom, discrimination in the NHS, health and energy efficiency schemes, the regulation of independent hospitals and the partnership between the public and the private sectors, to name but a few, are minor and technical? Is that illustrative of the contempt that she feels for the national health service which she claims to uphold?

Mrs. Beckett: Uncharacteristically, the hon. Gentleman has misunderstood what I said and I am sure


that he would not wish to do so. I did not say that the issues in question were minor and technical but that the amendments were.

Sir Patrick Cormack: Would the right hon. Lady be kind enough to answer a question asked by my right hon. Friend the Member for North-West Hampshire (Sir G. Young) and tell us how much time will be allowed for the Health Bill? Why is it necessary to guillotine the Immigration and Asylum Bill, which the House has not even begun to discuss and about which many Labour Members have strong views, as we know? In answer to the question posed by my right hon. and learned Friend the Member for Sleaford and North Hykeham (Mr. Hogg), will she tell us how long we shall have for that Bill?

Mrs. Beckett: The motion will be tabled following the conclusion of this business statement. There will be sufficient time for the debates and the Government have given proper consideration—as we would have done if we had been able to discuss a sensible programme motion—to allowing the House adequate time to debate these matters.

DELEGATED LEGISLATION

Motion made, and Question put forthwith, pursuant to Standing Order No. 118(6) (Standing Committees on Delegated Legislation),

NORTHERN IRELAND

That the draft Northern Ireland (Emergency and Prevention of Terrorism Provisions) (Continuance) Order 1999, which was laid before this House on 13th May, be approved.—[Jane Kennedy.]

Question agreed to.

TRUSTEE DELEGATION BILL [LORDS]

Order for Second Reading read.

Motion made, and Question put forthwith, pursuant to Standing Order No. 90(6) (Second Reading Committees), That the Bill be now read a Second time.

Question agreed to.

Bill accordingly read a Second time, and committed to a Standing Committee, pursuant to Standing Order No. 63 (Committal of Bills).

DELEGATED LEGISLATION

Motion made, and Question put forthwith, pursuant to Standing Order No. 118(6) (Standing Committees on Delegated Legislation),

DEFENCE

That the draft Army, Air Force and Naval Discipline Acts (Continuation) Order 1999, which was laid before this House on 6th May, be approved.—[Jane Kennedy.]i

Question agreed to.

Motion made, and Question put forthwith, pursuant to Standing Order No.118(6) (Standing Committees on Delegated Legislation),

PROFESSIONS SUPPLEMENTARY TO MEDICINE

That the draft Professions Supplementary to Medicine (Clinical Scientists Board) Order of Council 1999, which was laid before this House on 18th May, be approved.—[Jane Kennedy.]

The House divided: Ayes 314, Noes 136.

Division No. 202]
[10.16 pm


AYES


Abbott, Ms Diane
Curtis-Thomas, Mrs Claire


Ainger, Nick
Dalyell, Tam


Alexander, Douglas
Darling, Rt Hon Alistair


Allen, Graham
Darvill, Keith


Anderson, Donald (Swansea E)
Davey, Valerie (Bristol W)


Armstrong, Rt Hon Ms Hilary
Davidson, Ian


Ashton, Joe
Davies, Rt Hon Denzil (Llanelli)


Atherton, Ms Candy
Davies, Geraint (Croydon C)


Atkins, Charlotte
Dawson, Hilton


Barnes, Harry
Dean, Mrs Janet


Barron, Kevin
Denham, John


Beard, Nigel
Dismore, Andrew


Beckett, Rt Hon Mrs Margaret
Dobbin, Jim


Begg, Miss Anne
Dobson, Rt Hon Frank


Benn, Hilary (Leeds C)
Donohoe, Brian H


Benn, Rt Hon Tony (Chesterfield)
Doran, Frank


Bennett, Andrew F
Dowd, Jim


Berry, Roger
Drew, David


Best, Harold
Dunwoody, Mrs Gwyneth


Betts, Clive
Eagle, Angela (Wallasey)


Blackman, Liz
Eagle, Maria (L'pool Garston)


Blears, Ms Hazel
Edwards, Huw


Blizzard, Bob
Efford, Clive


Bradley, Keith (Withington)
Ellman, Mrs Louise


Bradley, Peter (The Wrekin)
Ennis, Jeff


Bradshaw, Ben
Fisher, Mark


Brinton, Mrs Helen
Fitzpatrick, Jim


Brown, Russell (Dumfries)
Fitzsimons, Lorna


Browne, Desmond
Flint, Caroline


Buck, Ms Karen
Follett, Barbara


Burden, Richard
Foster, Michael Jabez (Hastings)


Burgon, Colin
Foster, Michael J (Worcester)


Butler, Mrs Christine
Foulkes, George


Caborn, Rt Hon Richard
Galloway, George


Campbell, Alan (Tynemouth)
Gapes, Mike


Campbell, Mrs Anne (C'bridge)
Gardiner, Barry



Campbell, Ronnie (Blyth V)
George, Bruce (Walsall S)


Campbell—Savours, Dale
Gerrard, Neil


Cann, Jamie
Gibson, Dr Ian


Caton, Martin
Gilroy, Mrs Linda


Cawsey, Ian
Godman, Dr Norman A


Cawsey, Ian
Godman, Dr Norman A


Chapman, Ben (Wirral S)
Godsiff, Roger


Chaytor, David
Goggins, Paul


Chisholm, Malcolm
Golding, Mrs Llin


Clapham, Michael
Gordon, Mrs Eileen


Clark, Dr Lynda (Edinburgh Pentlands)
Griffiths, Jane (Reading E)



Griffiths, Nigel (Edinburgh S)


Clark, Paul (Gillingham)
Griffiths, Win (Bridgend)


Clarke, Charles (Norwich S)
Grocott, Bruce


Clarke, Rt Hon Tom (Coatbridge)
Grogan, John


Clarke, Tony (Northampton S)
Hain, Peter


Clelland, David
Hall, Mike (Weaver Vale)


Clwyd, Ann
Hall, Patrick (Bedford)


Coaker, Vernon
Hamilton, Fabian (Leeds NE)


Coffey, Ms Ann
Hanson, David


Cohen, Harry
Harman, Rt Hon Ms Harriet


Coleman, Iain
Heal, Mrs Sylvia


Colman, Tony
Healey, John


Connarty, Michael
Henderson, Ivan (Harwich)


Corbett, Robin
Hepburn, Stephen


Corston, Ms Jean
Heppell, John


Cousins, Jim
Hesford, Stephen


Cranston, Ross
Hewitt, Ms Patricia


Cryer, John (Hornchurch)
Hinchliffe, David


Cummings, John
Hoey, Kate


Cunningham, Rt Hon Dr Jack (Copeland)
Hoon, Geoffrey



Hope, Phil






Hopkins, Kelvin
Morris, Rt Hon John (Aberavon)


Howarth, George (Knowsley N)
Mountford, Kali


Howells, Dr Kim
Mudie, George


Hoyle, Lindsay
Mullin, Chris


Hughes, Ms Beverley (Stretford)
Murphy, Denis (Wansbeck)


Hughes, Kevin (Doncaster N)
Murphy, Jim (Eastwood)


Humble, Mrs Joan
Naysmith, Dr Doug


Hurst, Alan
Norris, Dan


Hutton, John
O'Brien, Bill (Normanton)


Jackson, Ms Glenda (Hampstead)
O'Brien, Mike (N Warks)


Jamieson, David
Olner, Bill


Jenkins, Brian
O'Neill, Martin


Johnson, Alan (Hull W & Hessle)
Organ, Mrs Diana


Johnson, Miss Melanie (Welwyn Hatfield)
Osborne, Ms Sandra



Palmer, Dr Nick


Jones, Barry (Alyn & Deeside)
Pearson, Ian


Jones, Helen (Warrington N)
Pendry, Tom


Jones, Jon Owen (Cardiff C)
Pickthall, Colin


Jones, Dr Lynne (Selly Oak)
Pike, Peter L


Jones, Martyn (Clwyd S)
Plaskitt, James


Keeble, Ms Sally
Pond, Chris


Keen, Alan (Feltham & Heston)
Pope, Greg


Keen, Ann (Brentford & Isleworth)
Pound, Stephen


Kemp, Fraser
Powell, Sir Raymond


Kennedy, Jane (Wavertree)
Prentice, Ms Bridget (Lewisham E)


Khabra, Piara S
Prentice, Gordon (Pendle)


Kidney, David
Prescott, Rt Hon John


King, Andy (Rugby & Kenilworth)
Primarolo, Dawn


King, Ms Oona (Bethnal Green)
Prosser, Gwyn


Kumar, Dr Ashok
Purchase, Ken


Ladyman, Dr Stephen
Quin, Rt Hon Ms Joyce


Lawrence, Ms Jackie
Quinn, Lawrie


Laxton, Bob
Rammell, Bill


Lepper, David
Reed, Andrew (Loughborough)


Leslie, Christopher
Reid, Rt Hon Dr John (Hamilton N)


Levitt, Tom
Roche, Mrs Barbara


Lewis, Ivan (Bury S)
Rooker, Jeff


Lewis, Terry (Worsley)
Rooney, Terry


Liddell, Rt Hon Mrs Helen
Ross, Ernie (Dundee W)


Linton, Martin
Rowlands, Ted


Livingstone, Ken
Roy, Frank


Lloyd, Tony (Manchester C)
Ruane, Chris


Lock, David
Ruddock, Joan


McAllion, John
Russell, Ms Christine (Chester)


McAvoy, Thomas
Ryan, Ms Joan


McCabe, Steve
Salter, Martin


McDonagh, Siobhain
Savidge, Malcolm


Macdonald, Calum
Sawford, Phil


McDonnell, John
Sedgemore, Brian


McGuire, Mrs Anne
Shaw, Joanthan


McIsaac, Shona
Sheerman, Barry


Mackinlay, Andrew
Short, Rt Hon Clare


McNulty, Tony
Simpson, Alan (Nottingham S)


MacShane, Denis
Skinner, Dennis


Mactaggart, Fiona
Smith, Rt Hon Andrew (Oxford E)


McWalter, Tony
Smith, Angela (Basildon)


McWilliam, John
Smith, Jacqui (Redditch)


Mallaber, Judy
Smith, John (Glamorgan)


Mandelson, Rt Hon Peter
Smith, Llew (Blaenau Gwent)


Marsden, Paul (Shrewsbury)
Soley, Clive


Marshall, David (Shettleston)
Southworth, Ms Helen


Marshall—Andrews, Robert
Squire, Ms Rachel


Martlew, Eric
Steinberg, Gerry


Maxton, John
Stevenson, George


Meacher, Rt Hon Michael
Stewart, David (Inverness E)



Meale, Alan
Steward, Ian (Eccles)


Merron, Gillian
Stinchcombe, Paul


Michie, Bill (Shef'ld Heeley)
Stoate, Dr Howard


Miller, Andrew
Stott, Roger


Moffatt, Laura
Strange, Rt Hon Dr Gavin


Moonie, Dr Lewis
Straw, Rt Hon Jack


Moran, Ms Margaret
Stringer, Graham


Morgan, Ms Julie (Cardiff N)
Stuart, Ms Gisela


Morgan, Rhodri (Cardiff W)
Sutcliffe, Gerry


Morley, Elliot
Taylor, Rt Hon Mrs Ann (Dewsbury)


Morris, Ms Estelle (B'ham Yardley)






Taylor, Ms Dari (Stockton S)
Watts, David


Temple—Morris, Peter
White, Brian


Thomas, Gareth (Clwyd W)
Whitehead, Dr Alan


Thomas, Gareth R (Harrow W)
Wicks, Malcolm


Tipping, Paddy
Williams, Alan W (E Carmarthen)


Todd, Mark
Williams, Mrs Betty (Conwy)


Touhig, Don
Wills, Michael


Trickett, Jon
Winnick, David


Truswell, Paul
Winterton, Ms Rosie (Doncaster C)


Turner, Dennis (Wolverh'ton SE)
Wise, Audrey


Turner, Dr Desmond (Kemptown)
Wood, Mike


Turner, Dr George (NW Norfolk)
Worthington, Tony


Twigg, Derek (Halton)
Wright, Anthony D (Gt Yarmouth)


Twigg, Stephen (Enfield)
Wright, Dr Tony (Cannock)


Vaz, Keith



Walley, Ms Joan
Tellers for the Ayes:


Ward, Ms Claire
Mr. Robert Ainsworth and


Wareing, Robert N
Mr. Keith Hill.




NOES


Ainsworth, Peter (E Surrey)
Horam, John


Allan, Richard
Howarth, Gerald (Aldershot)


Amess, David
Hughes, Simon (Southwark N)


Arbuthnot, Rt Hon James
Hunter, Andrew


Baldry, Tony
Jack, Rt Hon Michael


Ballard, Jackie
Jackson, Robert (Wantage)


Beith, Rt Hon A J
Jenkin, Bernard


Bell, Martin (Tatton)
Keetch, Paul


Bercow, John
Key, Robert


Beresford, Sir Paul
King, Rt Hon Tom (Bridgwater)


Body, Sir Richard
Kirkbride, Miss Julie


Boswell, Tim
Kirkwood, Archy


Brady, Graham
Laing, Mrs Eleanor



Brazier, Julian
Lait, Mrs Jacqui


Brooke, Rt Hon Peter
Lansley, Andrew


Browning, Mrs Angela
Letwin, Oliver


Bruce, Ian (S Dorset)
Lewis, Dr Julian (New Forest E)


Burnett, John
Lidington, David


Burns, Simon
Livsey, Richard


Butterfill, John
Lloyd, Rt Hon Sir Peter (Fareham)


Cash, William
Loughton, Tim


Chope, Christopher
Luff, Peter


Clappison, James
MacGregor, Rt Hon John


Clark, Dr Michael (Rayleigh)
McIntosh, Miss Anne


Clarke, Rt Hon Kenneth (Rushcliffe)
Maclean, Rt Hon David



Maclennan, Rt Hon Robert


Cormack, Sir Patrick
McLoughlin, Patrick


Cran, James
Madel, Sir David


Davies, Quentin (Grantham)
Maples, John


Davis, Rt Hon David (Haltemprice)
Mawhinney, Rt Hon Sir Brian


Day, Stephen
May, Mrs Theresa


Duncan, Alan
Michie, Mrs Ray (Argyll & Bute)


Duncan Smith, Iain
Moore, Michael


Evans, Nigel
Moss, Malcolm


Faber, David
Nicholls, Patrick


Fabricant, Michael
Norman, Archie


Fearn, Ronnie
Page, Richard


Flight, Howard
Paice, James


Forth, Rt Hon Eric
Paterson, Owen


Fraser, Christopher
Pickles, Eric


Garnier, Edward
Randall, John


Gibb, Nick

Redwood, Rt Hon John


Gill, Christopher
Rendel, David


Gorman, Mrs Teresa
Robertson, Laurence (Tewk'b'ry)


Gray, James
Russell, Bob (Colchester)


Green, Damian
St Aubyn, Nick


Greenway, John
Sanders, Adrian


Grieve, Dominic
Sayeed, Jonathan


Hague, Rt Hon William
Simpson, Keith (Mid-Norfolk)


Hammond, Philip
Smith, Sir Robert (W Ab'd'ns)


Harris, Dr Evan
Soames, Nicholas


Harvey, Nick
Spring, Richard


Hawkins, Nick
Spring, Richard


Hayes, John
Steen, Anthony


Heald, Oliver
Streeter, Gary


Hogg, Rt Hon Douglas
Stunell, Andrew







Swayne, Desmond
Waterson, Nigel


Syms, Robert
Webb, Steve


Tapsell, Sir Peter
Whitney, Sir Raymond


Taylor, Ian (Esher & Walton)
Whittingdale, John


Taylor, Sir Teddy
Widdecombe, Rt Hon Miss Ann


Tonge, Dr Jenny
Wilkinson, John



Tredinnick, David
Willetts, David


Trend, Michael
Willis, Phil


Tyler, Paul
Winterton, Mrs Ann (Congleton)


Tyne, Andrew
Winterton, Nicholas (Macclesfield)


Viggers, Peter
Young, Rt Hon Sir George


Wallace, James
Tellers for the Noes:


Walter, Robert
Mr. John M. Taylor and


Wardle, Charles
Mr. Tim Collins.

Question accordingly agreed to.

Motion made, and Question put forthwith, pursuant to Standing Order No. 118(6) (Standing Committees on Delegated Legislation),

PROFESSIONS SUPPLEMENTARY TO MEDICINE

That the draft Professions Supplementary to Medicine (Speech and Language Therapists Board) Order of Council 1999, which was laid before this House on 18th May, be approved.—[Jane Kennedy.]

The House divided: Ayes 337, Noes 110.

Division No. 203]
[10.30 pm


AYES


Abbott, Ms Diane
Campbell—Savours, Dale


Ainger, Nick
Cann, Jamie


Alexander, Douglas
Caton, Martin


Allan, Richard
Cawsey, Ian


Allen, Graham
Chapman, Ben (Wirral S)


Anderson, Donald (Swansea E)
Chaytor, David


Armstrong, Rt Hon Ms Hilary
Chisholm, Malcolm


Ashton, Joe
Clapham, Michael


Atherton, Ms Candy
Clark, Dr Lynda (Edinburgh Pentlands)


Atkins, Charlotte



Ballard, Jackie
Clark, Paul (Gillingham)


Barnes, Harry
Clarke, Charles (Norwich S)


Barron, Kevin
Clarke, Rt Hon Tom (Coatbridge)


Beard, Nigel
Clarke, Tony (Northampton S)


Beckett, Rt Hon Mrs Margaret
Clelland, David


Begg, Miss Anne
Clwyd, Ann


Beith, Rt Hon A J
Coaker, Vernon


Bell, Martin (Tatton)
Coffey, Ms Ann


Benn, Hilary (Leeds C)
Cohen, Harry


Benn, Rt Hon Tony (Chesterfield)
Coleman, Iain


Bennett, Andrew F
Colman, Tony


Berry, Roger
connarty, Michael


Best, Harold
Corbett, Robin


Betts, Clive
Corston, Ms Jean


Blackman, Liz
Cousins, Jim


Blears, Ms Hazel
Cranston, Ross


Blizzard, Bob
Cryer, John (Hornchurch)


Bradley, Keith (Withington)
Cummings, John


Bradley, Peter (The Wrekin)
Cunningham, Rt Hon Dr Jack (Copeland)


Bradshaw, Ben



Brinton, Mrs Helen
Curtis—Thomas, Mrs Claire


Brown, Russell (Dumfries)
Dalyell, Tam


Browne, Desmond
Darling, Rt Hon Alistair


Buck, Ms Karen
Darvill, Keith


Burden, Richard
Davey, Valerie (Bristol W)


Burgon, Colin
Davidson, Ian


Burnett, John
Davies, Rt Hon Denzil (Llanelli)


Butler, Mrs Christine
Davies, Geraint (Croydon C)


Caborn, Rt Hon Richard
Dawson, Hilton


Campbell, Alan (Tynemouth)
Dean, Mrs Janet


Campbell, Mrs Anne (C'bridge)
Denham, John


Campbell, Rt Hon Menzies (NE Fife)
Dismore, Andrew



Dobbin, Jim


Campbell, Ronnie (Blyth V)
Dobson, St Hon Frank





Donohoe, Brian H
Keeble, Ms Sally


Doran, Frank
Keen, Alan (Feltham & Heston)


Dowd, Jim
Keen, Ann (Brentford & Isleworth)


Drew, David
Keetch, Paul


Eagle, Angela (Wallasey)
Kemp, Fraser


Eagle, Maria (L'pool Garston)
Kennedy, Jane (Wavertree)


Edwards, Huw
Khabra, Piara S


Efford, Clive
Kidney, David


Ellman, Mrs Louise
King, Andy (Rugby & Kenilworth)


Ennis, Jeff
King, Ms Oona (Bethnal Green)


Fearn, Ronnie
Kirkwood, Archy


Fisher, Mark
Kumar, Dr Ashok


Fitzpatrick, Jim
Ladyman, Dr Stephen


Fitzsimons, Lorna
Lawrence, Ms Jackie


Flint, Caroline
Laxton, Bob


Follett, Barbara
Lepper, David


Foster, Michael Jabez (Hastings)
Leslie, Christopher


Foster, Michael J (Worcester)
Levitt, Tom


Foulkes, George
Lewis, Ivan (Bury S)


Galloway, George
Lewis, Terry (Worsley)


Gapes, Mike
Liddell, Rt Hon Mrs Helen


Gardiner, Barry
Linton, Martin


George, Bruce (Walsall S)
Livingston, Ken


Gerrard, Neil
Livsey, Richard


Gibson, Dr Ian
Lloyd, Tony (Manchester C)


Gilroy, Mrs Linda
Lock, David


Godman, Dr Norman A
McAllion, John


Godsiff, Roger
McAvoy, Thomas


Goggins, Paul
McCabe, Steve


Golding, Mrs Llin
McDonagh, Siobhain


Gordon, Mrs Eileen
Macdonald, Calum


Griffiths, Jane (Reading E)
McDonnell, John


Griffiths, Nigel (Edinburgh S)
McGuire, Mrs Anne


Griffiths, Win (Bridgend)
McIsaac, Shona


Grocott, Bruce
Mackinlay, Andrew


Grogan, John
Maclennan, Rt Hon Robert


Hain, Peter
McNulty, Tony


Hall, Mike (Weaver Vale)
MacShane, Denis


Hall, Patrick (Bedford)
Mactaggart, Fiona


Hamilton, Fabian (Leeds NE)
McWalter, Tony


Hanson, David
McWilliam, John


Harman, Rt Hon Ms Harriet
Mallaber, Judy


Harris, Dr Evan
Mandelson, Rt Hon Peter


Harvey, Nick
Marsden, Paul (Shrewsbury)


Heal, Mrs Sylvia
Marshall, David (Shettleston)


Healey, John
Marshall—Andrews, Robert


Henderson, Ivan (Harwich)
Martlew, Eric


Hepburn, Stephen
Maxton, John


Heppell, John
Meacher, Rt Hon Michael


Hesford, Stephen
Meale, Alan


Hewitt, Ms Patricia
Merron, Gillian


Hinchliffe, David
Michie, Bill (Shef'ld Heeley)


Hoey, Kate
Michie, Mrs Ray (Argyll & Bute)


Hoon, Geoffrey
Miller, Andrew


Hope, Phil
Moffatt, Laura


Hopkins, Kelvin
Moonie, Dr Lewis


Howarth, George (Knowsley N)
Moore, Michael


Howells, Dr Kim
Moran, Ms Margaret


Hoyle, Lindsay
Morgan, Alasdair (Galloway)


Hughes, Ms Beverley (Stretford)
Morgan, Ms Julie (Cardiff N)


Hughes, Kevin (Doncaster N)
Morgan, Rhodri (Cardiff W)


Hughes, Simon (Southwark N)
Morley, Elliot


Humble, Mrs Joan
Morris, Ms Estelle (B'ham Yardley)


Hurst, Alan
Mountford, Kali


Hutton, John
Mudie, George


Jackson, Ms Glenda (Hampstead)
Mullin, Chris


Jamieson, David
Murphy, Denis (Wansbeck)


Jenkins, Brian
Murphy, Jim (Eastwood)



Johnson, Alan (Hull W & Hessle)
Naysmith, Dr Doug


Johnson, Miss Melanie (Welwyn Hatfield)
Norris, Dan



O'Brien, Bill (Normanton)


Jones, Barry (Alyn & Deeside)
O'Brien, Mike (N Warks)


Jones, Helen (Warrington N)
Olner, Bill


Jones, Jon Owen (Cardiff C)
O'Neill, Martin


Jones, Dr Lynne (Selly Oak)
Organ, Mrs Diana


Jones, Martyn (Clwyd S)
Osborne, Ms Sandra






Palmer, Dr Nick
Stewart, David (Inverness E)


Pearson, Ian
Stewart, Ian (Eccles)


Pendry, Tom
Stinchcombe, Paul


Pickthall, Colin
Stoate, Dr Howard


Pike, Peter L
Stott, Roger


Plaskitt, James
Strang, Rt Hon Dr Gavin


Pond, Chris
Stringer, Graham


Pope, Greg
Stuart, Ms Gisela


Powell, Sir Raymond
Stunell, Andrew


Prentice, Ms Bridget (Lewisham E)
Sutcliffe, Gerry


Prentice, Gordon (Pendle)
Taylor, Rt Hon Mrs Ann (Dewsbury)


Prescott, Rt Hon John



Primarolo, Dawn
Taylor, Ms Dari (Stockton S)


Prosser, Gwyn
Temple—Morris, Peter


Purchase, Ken
Thomas, Gareth (Clwyd W)


Quin, Rt Hon Ms Joyce
Thomas, Gareth R (Harrow W)


Quinn, Lawrie
Tipping, Paddy


Rammell, Bill
Todd, Mark


Reed, Andrew (Loughborough)
Tonge, Dr Jenny


Reid Rt Hon Dr John (Hamilton N)
Touhig, Don


Rendel, David
Trickett, Jon


Roche, Mrs Barbara
Truswell, Paul


Rooker, Jeff
Turner, Dennis (Wolverh'ton SE)


Rooney, Terry
Turner, Dr Desmond (Kemptown)


Ross, Ernie (Dundee W)
Turner, Dr George (NW Norfolk)


Rowlands, Ted
Twigg, Derek (Halton)


Roy, Frank
Twigg, Stephen (Enfield)


Ruane, Chris
Tyler, Paul


Ruddock, Joan
Vaz, Keith


Russell, Bob (Colchester)
Wallace, James


Russell, Ms Christine (Chester)
Walley, Ms Joan


Ryan, Ms Joan
Ward, Ms Claire


Salter, Martin
Wareing, Robert N


Sanders, Adrian
Watts, David


Savidge, Malcolm
Webb, Steve


Sawford, Phil
White, Brian


Sedgemore, Brian
Whitehead, Dr Alan


Shaw, Jonathan
Wicks, Malcolm


Sheerman, Barry
Williams, Alan W (E Carmarthen)


Short, Rt Hon Clare
Williams, Mrs Betty (Conwy)


Simpson, Alan (Nottingham S)
Willis, Phil


Skinner, Dennis
Wills, Michael


Smith, Rt Hon Andrew (Oxford E)
Winnick, David


Smith, Angela (Basildon)
Winterton, Ms Rosie (Doncaster C)


Smith, Jacqui (Redditch)

Wise, Audrey


Smith, John (Glamorgan)
Wood, Mike


Smith, Llew (Blaenau Gwent)
Worthington, Tony


Smith, Sir Robert (W Ab'd'ns)
Wright, Anthony D (Gt Yarmouth)


Soley, Clive
Wright, Dr Tony (Cannock)


Southworth, Ms Helen



Squire, Ms Rachel
Tellers for the Ayes:


Steinberg, Gerry
Mr. Robert Ainsworth and


Stevenson, George
Mr. Keith Hill.




NOES


Ainsworth, Peter (E Surrey)
Cormack, Sir Patrick


Amess, David
Cran, James


Arbuthnot, Rt Hon James
Davies, Quentin (Grantham)


Baldry, Tony
Davis, Rt Hon David (Haltemprice)


Bercow, John
Day, Stephen


Beresford, Sir Paul
Duncan, Alan


Body, Sir Richard
Duncan Smith, Iain


Boswell, Tim
Evans, Nigel


Brady, Graham
Faber, David


Brazier, Julian
Fabricant, Michael


Brooke, Rt Hon Peter
Flight, Howard


Browning, Mrs Angela
Forth, Rt Hon Eric


Bruce, Ian (S Dorset)
Fraser, Christopher


Burns, Simon
Garnier, Edward


Butterfill, John
Gibb, Nick


Cash, William
Gill, Christopher


Chope, Christopher
Gorman, Mrs Teresa


Clappison, James
Gray, James


Clark, Dr Michael (Rayleigh)
Green, Damian


Clarke, Rt Hon Kenneth (Rushcliffe)
Greenway, John



Grieve, Dominic





Hammond, Philip
Pickles, Eric


Hawkins, Nick
Randall, John


Hayes, John
Redwood, Rt Hon John


Heald, Oliver
Robertson, Laurence (Tewk'b'ry)


Hogg, Rt Hon Douglas
St Aubyn, Nick


Horam, John
Sayeed, Jonathan


Howarth, Gerald (Aldershot)
Simpson, Keith (Mid-Norfolk)


Jack, Rt Hon Michael
Soames, Nicholas


Jackson, Robert (Wantage)
Spring, Richard


Jenkin, Bernard
Stanley, Rt Hon Sir John


Key, Robert
Steen, Anthony


King, Rt Hon Tom (Bridgwater)
Streeter, Gary


Kirkbride, Miss Julie
Swayne, Desmond


Laing, Mrs Eleanor
Syms, Robert


Lait, Mrs Jacqui
Tapsell, Sir Peter


Lansley, Andrew
Taylor, Ian (Esher & Walton)


Letwin, Oliver
Taylor, Sir Teddy


Lewis, Dr Julian (New Forest E)
Tredinnick, David


Lidington, David
Trend, Michael


Lloyd, Rt Hon Sir Peter (Fareham)
Tyrie, Andrew


Loughton, Tim
Viggers, Peter


Luff, Peter



MacGregor, Rt Hon John
Walter, Robert


McIntosh, Miss Anne
Wardle, Charles


Maclean, Rt Hon David
Waterson, Nigel



Whitney, Sir Raymond


McLoughlin, Patrick
Whittingdale, John



Widdecombe, Rt Hon Miss Ann


Madel, Sir David
Wilkinson, John


Maples, John
Willetts, David


Mawhinney, Rt Hon Sir Brian
Winterton, Mrs Ann (Congleton)


May, Mrs Theresa
Winterton, Nicholas (Macclesfield)


Moss, Malcolm
Yeo, Tim


Nicholls, Patrick
Young, Rt Hon Sir George


Norman, Archie



Page, Richard
Tellers for the Noes:


Paice, James
Mr. John M. Taylor and


Paterson, Owen
Mr. Tim Collins.

Question accordingly agreed to.

Motion made, and Question put forthwith, pursuant to Standing Order No. 118(6) (Standing Committees on Delegated Legislation),

PROFESSIONS SUPPLEMENTARY TO MEDICINE

That the draft Professions Supplementary to Medicine (Paramedics Board) Order of Council 1999, which was laid before this House on 18th May, be approved.—[Jane Kennedy.]

The House divided: Ayes 334, Noes 109.

Division No. 204]
[10.43 pm



AYES


Ainger, Nick
Betts, Clive


Alexander, Douglas
Blackman, Liz


Allan, Richard
Blears, Ms Hazel


Allen, Graham
Blizzard, Bob


Anderson, Donald (Swansea E)
Bradley, Keith (Withington)


Armstrong, Rt Hon Ms Hilary
Bradley, Peter (The Wrekin)


Ashton, Joe
Bradshaw, Ben


Atherton, Ms Candy
Brinton, Mrs Helen


Atkins, Charlotte
Brown, Russell (Dumfries)


Ballard, Jackie
Browne, Desmond


Barnes, Harry
Buck, Ms Karen


Barron, Kevin
Burden, Richard


Beard, Nigel
Burgon, Colin


Beckett, Rt Hon Mrs Margaret
Burnett, John


Begg, Miss Anne
Butler, Mrs Christine


Beith, Rt Hon A J
Caborn, Rt Hon Richard


Bell, Martin (Tatton)
Campbell, Alan (Tynemouth)


Benn, Hilary (Leeds C)
Campbell, Mrs Anne (C'bridge)


Benn, Rt Hon Tony (Chesterfield)
Campbell, Rt Hon Menzies (NE Fife)


Bennett, Andrew F



Berry, Roger
Campbell, Ronnie (Blyth V)


Best, Harold
Campbell—Savours, Dale






Cann, Jamie
Griffiths, Win (Bridgend)


Caton, Martin
Grocott, Bruce


Cawsey, Ian
Grogan, John


Chapman, Ben (Wirral S)
Hain, Peter


Chaytor, David
Hall, Mike (Weaver Vale)


Chisholm, Malcolm
Hall, Patrick (Bedford)


Clapham, Michael
Hamilton, Fabian (Leeds NE)


Clark, Dr Lynda (Edinburgh Pentlands)
Hanson, David



Harman, Rt Hon Ms Harriet


Clark, Paul (Gillingham)
Harris, Dr Evan


Clarke, Charles (Norwich S)
Heal, Mrs Sylvia


Clarke, Rt Hon Tom (Coatbridge)
Healey, John


Clarke, Tony (Northampton S)
Henderson, Ivan (Harwich)



Clelland, David
Hepburn, Stephen


Clwyd, Ann
Heppell, John


Coaker, Vernon
Hesford, Stephen


Coffey, Ms Ann
Hewitt, Ms Patricia


Cohen, Harry
Hinchliffe, David


Coleman, Iain
Hoey, Kate


Colman, Tony
Hoon, Geoffrey


Connarty, Michael
Hope, Phil


Corbett, Robin
Hopkins, Kelvin


Corston, Ms Jean
Howarth, George (Knowsley N)


Cousins, Jim
Howells, Dr Kim


Cranston, Ross
Hoyle, Lindsay


Cryer, John (Hornchurch)
Hughes, Ms Beverley (Stretford)


Cummings, John
Hughes, Kevin (Doncaster N)


Cunningham, Rt Hon Dr Jack (Copeland)
Hughes, Simon (Southwark N)



Humble, Mrs Joan


Curtis—Thomas, Mrs Claire
Hurst, Alan


Dalyell, Tam
Hutton, John


Darling, Rt Hon Alistair
Jackson, Ms Glenda (Hampstead)


Darvill, Keith
Jamieson, David


Davey, Valerie (Bristol W)
Jenkins, Brian


Davidson, Ian
Johnson, Alan (Hull W & Hessle)


Davies, Rt Hon Denzil (Llanelli)
Johnson, Miss Melanie (Welwyn Hatfield)


Davies, Geraint (Croydon C)



Dawson, Hilton
Jones, Barry (Alyn & Deeside)


Dean, Mrs Janet
Jones, Helen (Warrington N)


Denham, John
Jones, Jon Owen (Cardiff C)


Dismore, Andrew
Jones, Dr Lynne (Selly Oak)


Dobbin, Jim
Jones, Martyn (Clwyd S)


Dobson, Rt Hon Frank
Keeble, Ms Sally


Donohoe, Brian H
Keen, Alan (Feltham & Heston)


Doran, Frank
Keen, Ann (Brentford & Isleworth)


Dowd, Jim
Keetch, Paul


Drew, David
Kemp, Fraser


Eagle, Angela (Wallasey)
Kennedy, Jane (Wavertree)


Eagle, Maria (L'pool Garston)
Khabra, Piara S


Edwards, Huw
Kidney, David


Efford, Clive
King, Andy (Rugby & Kenilworth)


Ellman, Mrs Louise
King, Ms Oona (Bethnal Green)


Ennis, Jeff
Kirkwood, Archy


Fearn, Ronnie
Kumar, Dr Ashok


Fisher, Mark
Ladyman, Dr Stephen


Fitzpatrick, Jim
Lawrence, Ms Jackie


Fitzsimons, Lorna
Laxton, Bob


Flint, Caroline
Lepper, David


Follett, Barbara
Leslie, Christopher


Foster, Michael Jabez (Hastings)
Levitt, Tom


Foster, Michael J (Worcester)
Lewis, Ivan (Bury S)


Foulkes, George
Lewis, Terry (Worsley)


Galloway, George
Liddell, Rt Hon Mrs Helen


Gapes, Mike
Linton, Martin


Gardiner, Barry
Livingstone, Ken


George, Bruce (Walsall S)
Livsey, Richard


Gerrard, Neil
Lloyd, Tony (Manchester C)


Gibson, Dr Ian
Lock, David


Gilroy, Mrs Linda
McAllion, John


Godman, Dr Norman A
McAvoy, Thomas


Godsiff, Roger
McCabe, Steve


Goggins, Paul
McDonagh, Siobhain


Golding, Mrs Llin
Macdonald, Calum


Gordon, Mrs Eileen
McDonnell, John


Griffiths, Jane (Reading E)
McGuire, Mrs Anne


Griffiths, Nigel (Edinburgh S)
McIsaac, Shona





Mackinlay, Andrew
Salter, Martin


Maclennan, Rt Hon Robert
Sanders, Adrian


McNulty, Tony
Savidge, Malcolm


MacShane, Denis
Sawford, Phil


Mactaggart, Fiona
Sedgemore, Brian


McWalter, Tony
Shaw, Jonathan


McWilliam, John
Sheerman, Barry


Mallaber, Judy
Short, Rt Hon Clare


Mandelson, Rt Hon Peter
Skinner, Dennis


Marsden, Paul (Shrewsbury)
Smith, Rt Hon Andrew (Oxford E)


Marshall, David (Shettleston)
Smith, Angela (Basildon)


Marshall—Andrews, Robert
Smith, Jacqui (Redditch)


Martlew, Eric
Smith, John (Glamorgan)


Maxton, John
Smith, Llew (Blaenau Gwent)


Meacher, Rt Hon Michael
Smith, Sir Robert (W Ab'd'ns)


Meale, Alan
Soley, Clive


Merron, Gillian
Southworth, Ms Helen


Michie, Bill (Shef'ld Heeley)
Squire, Ms Rachel


Michie, Mrs Ray (Argyll & Bute)
Steinberg, Gerry


Miller, Andrew
Stevenson, George


Moffatt, Laura
Stewart, David (Inverness E)


Moonie, Dr Lewis
Stewart, Ian (Eccles)


Moore, Michael
Stinchcombe, Paul


Moran, Ms Margaret
Stoate, Dr Howard


Morgan, Alasdair (Galloway)
Stott, Roger


Morgan, Ms Julie (Cardiff N)
Strang, Rt Hon Dr Gavin


Morgan, Rhodri (Cardiff W)
Stringer, Graham


Motley, Elliot
Stuart, Ms Gisela


Morris, Ms Estelle (B'ham Yardley)
Stunell, Andrew


Mountford, Kali
Sutcliffe, Gerry


Mudie, George
Taylor, Rt Hon Mrs Ann (Dewsbury)


Mullin, Chris



Murphy, Denis (Wansbeck)
Taylor, Ms Dari (Stockton s)


Murphy, Jim (Eastwood)
Temple—Morris, Peter


Naysmith, Dr Doug
Thomas, Gareth (Clwyd W)


Norris, Dan
Thomas, Gareth R (Harrow W)


O'Brien, Bill (Normanton)
Tipping, Paddy


O'Brien, Mike (N Warks)
Todd, Mark


Olner, Bill
Tonge, Dr Jenny


O'Neill, Martin



Organ, Mrs Diana
Touhig, Don


Osborne, Ms Sandra
Trickett, Jon


Palmer, Dr Nick
Truswell, Paul


Pearson, Ian
Turner, Dennis (Wolverh'ton SE)


Pendry, Tom
Turner, Dr Desmond (Kemptown)


Pickthall, Colin
Turner, Dr George (NW Norfolk)


Pike, Peter L
Twigg, Derek (Halton)


Plaskitt, James
Twigg, Stephen (Enfield)


Pond, Chris
Tyler, Paul


Pope, Greg
Vaz, Keith


Powell, Sir Raymond
Wallace, James


Prentice, Ms Bridget (Lewisham E)
Walley, Ms Joan


Prentice, Gordon (Pendle)
Ward, Ms Claire


Prescott, Rt Hon John
Wareing, Robert N


Primarolo, Dawn
Watts, David


Prosser, Gwyn
Webb, Steve


Purchase, Ken
White, Brian


Quin, Rt Hon Ms Joyce
Whitehead, Dr Alan


Quinn, Lawrie
Wicks, Malcolm


Rammell, Bill
Williams, Alan W (E Carmarthen)


Reed, Andrew (Loughborough)
Williams, Mrs Betty (Conwy)


Reid, Rt Hon Dr John (Hamilton N)
Willis, Phil


Rendel, David
Wills, Michael


Roche, Mrs Barbara
Winnick, David


Rooker, Jeff
Winterton, Ms Rosie (Doncaster C)


Rooney, Terry
Wise, Audrey


Ross, Ernie (Dundee W)
Wood, Mike


Rowlands, Ted
Worthington, Tony


Roy, Frank
Wright, Anthony D (Gt Yarmouth)


Ruane, Chris
Wright, Dr Tony (Cannock)


Ruddock, Joan



Russell, Bob (Colchester)
Tellers for the Ayes:


Russell, Ms Christine (Chester)
Mr. Robert Ainsworth and


Ryan, Ms Joan
Mr. Keith Hill.






NOES


Ainsworth, Peter (E Surrey)
Lewis, Dr Julian (New Forest E)


Amess, David
Lidington, David


Arbuthnot, Rt Hon James
Lloyd, Rt Hon Sir Peter (Fareham)


Baldry, Tony
Loughton, Tim


Bercow, John
Luff, Peter


Beresford, Sir Paul
MacGregor, Rt Hon John


Body, Sir Richard
McIntosh, Miss Anne


Boswell, Tim
Maclean, Rt Hon David


Brady, Graham
McLoughlin, Patrick


Brazier, Julian
Madel, Sir David


Brooke, Rt Hon Peter
Maples, John


Browning, Mrs Angela
Mawhinney, Rt Hon Sir Brian


Bruce, Ian (S Dorset)
May, Mrs Theresa


Burns, Simon
Moss, Malcolm


Butterfill, John
Nicholls, Patrick


Cash, William
Norman, Archie


Chope, Christopher
Ottaway, Richard


Clappison, James
Page, Richard


Clarke, Rt Hon Kenneth (Rushcliffe)
Paice, James



Paterson, Owen


Cormack, Sir Patrick
Pickles, Eric


Cran, James
Randall, John


Davies, Quentin (Grantham)
Redwood, Rt Hon John


Davis, Rt Hon David (Haltemprice)
Robertson, Laurence (Tewk'b'ry)


Day, Stephen
St Aubyn, Nick


Duncan, Alan
Sayeed, Jonathan


Duncan Smith, Iain
Simpson, Keith (Mid-Norfolk)


Evans, Nigel
Soames, Nicholas


Faber, David
Spring, Richard


Fabricant, Michael
Stanley, Rt Hon Sir John


Flight, Howard
Steen, Anthony


Forth, Rt Hon Eric
Streeter, Gary


Fraser, Christopher
Swayne, Desmond


Garnier, Edward
Syms, Robert


Gibb, Nick
Tapsell, Sir Peter


Gill, Christopher
Taylor, Ian (Esher & Walton)


Gorman, Mrs Teresa
Taylor, John M (Solihull)


Gray, James
Taylor, Sir Teddy


Green, Damian
Tredinnick, David


Greenway, John
Trend, Michael


Grieve, Dominic
Tyrie, Andrew


Hammond, Philip
Viggers, Peter


Hawkins, Nick
Walter, Robert


Hayes, John
Wardle, Charles


Heald, Oliver
Waterson, Nigel


Hogg, Rt Hon Douglas
Whittingdale, John


Horam, John
Widdecombe, Rt Hon Miss Ann


Howarth, Gerald (Aldershot)
Wilkinson, John


Jack, Rt Hon Michael
Willetts, David


Jackson, Robert (Wantage)
Winterton, Mrs Ann (Congleton)


Jenkin, Bernard
Winterton, Nicholas (Macclesfield)


Key, Robert
Yeo, Tim


King, Rt Hon Tom (Bridgwater)
Young, Rt Hon Sir George


Kirkbride, Miss Julie



Lait, Mrs Jacqui
Tellers for the Noes:


Lansley, Andrew
Mrs. Eleanor Laing and


Letwin, Oliver
Mr. Tim Collins.

Question accordingly agreed to.

EUROPEAN COMMUNITY DOCUMENTS

Motion made, and Question put forthwith, pursuant to Standing Order No. 119(9) (European Standing Committees).

GLOBAL NAVIGATION SATELLITE SYSTEM

That this House takes note of European Union Document No. 6528/99, a Commission Communication: Galileo—involving Europe in a new generation of satellite navigation services; and endorses the Government's prudent approach to the Commission's proposals as set out in the Explanatory Memorandum.—[Jane Kennedy.]

Question agreed to.

EDUCATION AND EMPLOYMENT COMMITTEE

Ordered,

That Mr. Joe Benton be discharged from the Education and Employment Committee and Mr. Bill Rammell be added to the Committee.—[Mr. McWilliam, on behalf of the Committee of Selection.]

NORTHERN IRELAND AFFAIRS COMMITTEE

Ordered,

That Mr. Ken Livingstone be discharged from the Northern Ireland Affairs Committee and Mr. Stephen Pound be added to the Committee.—[Mr. McWilliam, on behalf of the Committee of Selection.]

Care in the Community

Motion made, and Question proposed, That this House do now adjourn.—[Jane Kennedy.]

Mr. Archie Norman: I am delighted to have this opportunity to raise the question of the care of the mentally handicapped—or as we now know them, people with learning disabilities—in the community. I am delighted not just because it gives me a break from the world of corporate mergers and takeovers but because it is a subject in which I have a very personal interest.
I have a brother who is mentally handicapped. He used to be accommodated in a national health service hospital and is now cared for in the community. The subject is also topical in my constituency because The Pines care home was recently threatened with closure. I want to raise the question of The Pines because it illustrates so many of the dilemmas and problems facing us concerning policy on the care of those with learning disabilities in the community.
The Pines was built only 11 years ago. At the time, the 24 residents, who are accommodated in clustered bungalows around their therapy centre, were assured that it would be a home for life, as were their relatives. Most of the residents were moved out of a major NHS hospital. Despite the home's being only 11 years old and ideal accommodation for the relatives and those who live there, it is threatened with closure by the area health authority.
It is not that there are not good arguments for closure or movement; there are of course two sides to every case. This case illustrates the extent to which local authorities and officials are pursuing a policy of accommodating people which to many seems doctrinaire—the policy of normalisation, pushing people with acute learning disabilities and mental handicap into
ordinary houses in ordinary streets",
despite the fact that, very often, such accommodation is uneconomic and wholly unsuitable for such people. The case also illustrates the lack of involvement of parents and relatives of people with learning disabilities. They are in many ways without any rights; there is a real sense of helplessness when faced with officialdom and official policy.
The Pines is not unique; similar situations arise in many areas across the country. The problem is growing, and is bound to, because, over the past 20 or so years, we have, for understandable reasons, closed so many long-stay beds in NHS hospitals for people with learning disabilities. The numbers have declined from 65,000 in the mid-1960s to 3,000 today. At the same time, the number of care in the community places has only risen from 7,300 to 36,000. By definition, therefore, many of the people previously accommodated in some permanent care of the state are now resident elsewhere.
There is already a shortfall in places. Restcare estimates a shortfall of some 25,000 residential places for people with mental handicap. An increase in demand is forecast for the next two decades because people with a handicap of one kind or another are expected to live longer. Many of these people are currently accommodated with ageing relatives, on whose death those residents will have to be moved into community care.
Now is the time for a thorough review of our whole approach to care in the community of those with learning disabilities. It is time to flush out and to tackle the dogma that has grown up following the abolition of the major residential hospitals, the understandable and absolutely correct move away from institutional care—the dogma that is all about normalisation, moving people into ordinary homes in ordinary streets. It is time to bring back a much more individual approach to care, and to create clustered homes in communities, which I believe to be the way of the future. It is time to create a framework of rights for those people who are, in a real sense, dispossessed by the health services and by the state. These people are in the possession of the state; they are totally dependent. They and their relatives need rights. It is time to clarify responsibility for these people as between the national health service, social services and local authorities.

Mr. John Burnett: I wonder whether the hon. Gentleman is aware of the judicial review of the case of Marden house in Exeter, in which the actions of the North and East Devon health authority were successfully challenged in the High Court—the case is now going to the Court of Appeal. A home just like the home that the hon. Gentleman described has been challenged successfully in the High Court. I wonder whether he is aware of that case, and whether that might be of some—

Mr. Deputy Speaker (Mr. Michael J. Martin): Order. The hon. Gentleman must be careful, because some matters are sub judice.

Mr. Burnett: I take that point, Mr. Deputy Speaker, and I am grateful to you. The case is going through the courts, but it does illustrate—

Mr. Deputy Speaker: Order. If the matter is going through the courts, it is not a matter for us to discuss this evening.

Mr. Norman: I am grateful to the hon. Gentleman for mentioning the case, which shows that the problem is prevalent throughout the country, and that the case in Tunbridge Wells is far from unique.
It is time to end the dogmatic approach and the view that there is one right solution: normalisation. It is time to bring back an investment in communities of people with a learning disability within which they can have a sense of companionship, belonging and role. I believe that there is a great deal more dignity for people with a learning disability if they can live together, if they can choose their friends within a community and if they can find a role in that community, than if they are in a sense isolated in an ordinary street, where they have very little contact with their neighbours and those who live locally.
The time has come to move to medium-sized and clustered homes and away from single houses in relative isolation. It is time to concentrate on care in the community, not dissipation in the community. Many residents today—

Mrs. Claire Curtis-Thomas: I should like to comment on some of the things that the hon. Gentleman has said. He mentioned the dogma of care in the


community. As the mother of a daughter with a learning difficulty, not a mental handicap—a term that I find wholly offensive—as someone with a sister with a learning difficulty and some physical difficulties and as, until recently, the daughter of a person who has quadriplegia, I very much welcome the inclusion of my relatives in a community, instead of the ghettoisation that the hon. Gentleman seems to be advocating. I believe that the latter would be a return to the past.
Most of us who are striving to get the best, not necessarily for an individual's parents, but for that individual, very much welcome the ethos that now pervades the social services. My experience of my community is that, at all times, it has tried to do the very best for the individuals whom I love and care for.

Mr. Norman: I thank the hon. Lady for enabling me to clarify the point. I am certainly not advocating a return to the past. The move away from the large, isolated institutions was absolutely right, but we must have the right policy for each individual. There are individuals—relatively able people with relatively slight learning disability—who are well accommodated and can be integrated in local communities and be cared for best in that way. There are problems with that approach—we understand that—but that may be right for some individuals. However, in the case of those with a more acute learning disability who need 24-hour care and attention, it is my experience and belief, which are shared by residents of The Pines and their relatives, that they value being part of a slightly larger community where their choices are greater.
Living in such a community enables people to select their friends from a wider circle. All too often, when they are moved into small homes, with perhaps only three, four or five residents, their friends and companions for life are selected by the state or by the local authority. That cannot be the right approach.
Very small homes are a much more expensive mode of care. There are various estimates of the cost, but it is clear from all those estimates that clustered homes where specialist care and facilities can be shared are likely to be more economic. In a document entitled "The Case for Residential and Village Communities" and prepared for the Rannoch Trust, Baroness Cox and Lord Pearson mentioned that Government figures for annual revenue costs for 1994 showed that it can cost £74,000 a year to support an individual in the community, whereas a place in a congregated village community with all services included can cost £25,000 a year.
There are questions about those calculations, but it is clear that some sharing of facilities is likely to be more economic. There will be a huge problem for the funding of such care, and the most important priority is that in future we should be able to finance the care that all people with a learning disability deserve.
It is estimated that 50 per cent. of those with an acute learning disability require more or less full-time or continuous medical support. It is much easier to provide such support in a slightly larger community.
It is important to remember that people put into ordinary houses in ordinary streets are totally dependent on their professional carer. There is no doubt that many carers are fantastic people who are devoted to the residents, but others have no great qualifications for the

role. They are working with people who have complex problems and need complex help and often medical support as well. There is an increased risk to residents who are in the hands of someone relatively unqualified for 24 hours a day. Grouping and clustering in village communities allows much better quality support.
The issue is not whether Government policy supports one form of care or another, but that we need clarification of the right circumstances for the individual. As the hon. Member for Crosby (Mrs. Curtis—Thomas) mentioned, it is a matter of finding the right situation to meet individual requirements. It is not clear how that should be done, although it is clear that, in different local authorities, different solutions are adopted.
Dr. Maurice Brook, vice-chairman of the National Society for Mentally Handicapped People in Residential Care, points out that all too often these people do not have much help or support. Many cannot make decisions without a great deal of help. Some have relatives who can stand up for them, but others do not. They are entirely in the hands of local officials. In many cases, as Dr. Brook states,
choice is often denied because of locally based officials.
He continues:
The most important test is the quality of life of an individual, not any ideological assumption about what model of care is best.
Whatever people may say, it is the experience of many that there is an official dogma regarding the best approach.
Dr. Brook goes on to state:
The views of parents and relatives should be treated as the views of an individual. In too many areas the Local Authority tries to impose their views. Those who are able to impose decisions that are in conflict with the wishes of parents and relatives are not democratically accountable.
I believe that many relatives across the country share that feeling. The time has come to review the entire framework.
The second major issue concerns the rights of those with a learning disability who are resident in homes supported by the NHS or social services. Although there is much talk of rights, in practice the experience of people such as the residents of The Pines and their relatives and the residents of many other homes across the country is that the reality does not match the talk. In too many instances, changes are made without adequate consultation, and where that consultation takes place it is often ignored. I shall illustrate that with the instance of The Pines. I have a letter in my possession written to residents by Kelsey Care, which is a sub-contracted care organisation. In most respects, it is a fine organisation. The letter is dated November 1990. It asks what would happen if ever there was a need or desire to move the residents elsewhere:
As the residents of The Pines will have either a tenancy agreement or a licence giving them a certain security of tenure, any decision would have to have the agreement of the persons concerned, parents or relatives, members of staff and the health authority.
In reality, that has turned out to be entirely untrue. Today, The Pines is threatened with closure. If it were not for the action taken by residents, many people would argue that it could be in the process of closure now, without adequate consultation and certainly without the permission of the relatives.
Is it not time that people who are so vulnerable and dependent on support from the state and residing in homes maintained by the national health service or by social services had an established set of rights of their own within a clear framework? A process should have to be followed before their lives can be entirely disrupted, before they can be taken to locations to live with people whom they might not know and not of their own choosing, and before they can be moved miles away from their relatives and their families? Is it not time that we established a basic framework that will prevent those things happening without the appropriate permissions and consents of those who are closest to them?
Is it not time there was a more effective process to encourage the involvement of parents and relatives? All too often, the system works to alienate those who should be supportive of people with learning disability in care. That applies not to those who have lived and been brought up at home with support, but in many instances to those who have been institutionalised and have lost touch with relatives.
One illustration concerns financial support. As parents age, people with a learning disability have to move into homes. It would be desirable if parents felt able to leave them bequests or moneys in other forms to provide enhanced support in future. Unfortunately, they fall into the classic means-testing trap whereby if the parents leave them money, that bequest represents a tort in terms of paying for their benefits. As a general practice, the making of bequests and the leaving of moneys in other forms is not done as much as it should be.
Should it not be an explicit part of the Government's policy and programme to involve parents and relatives more substantially and provide them with an on-going involvement or participation in the running of homes? Should not that be part of the new framework?
Is it not time to clarify responsibility for those with severe learning disability? Over the past 20 years, we have seen a huge transition from the NHS and the great NHS hospital institutions into local authority care. However, local authorities vary substantially in their approach to the problem and the way in which they make provision. It is well understood by those who are close to these matters that the level of benefits provided varies as well. Provision is patchy. The danger is that as local authority funding is squeezed, particularly in those areas where the cost of support and of property is much higher, it is the residents who will end up suffering.
Is it not time that, as we make the transition into local authority care and support from social services, the role of the NHS in terms of medical support should be clarified? An NHS Confederation document dated 14 June states:
There is a lack of core understanding of what the NHS is responsible for. This hampers service development. Access to general healthcare such as general practice, dental and ophthalmic services is poor.
It goes on:
There is no up-to-date national government policy on health services for people with learning disabilities. The last policy document was published in 1992 and is in urgent need of updating.

I know that some work is being done on updating that policy, but it is high time we had an outcome.
I believe that the time has come for a wholesale review of the framework of policy for those with learning disabilities who are cared for in the community. At times, it is hard to avoid forming the impression that that part of our community is a forgotten corner of society. All too often—as the great institutions are being closed, and rightly so, and as people emerge into the community—there is a risk that they will be dissipated in that community and lost in it; that parents will be disfranchised; and that the most vulnerable people will not be given the rights that we want to afford to them and which we would afford to the average citizen.

The Parliamentary Under-Secretary of State for Health (Mr. John Hutton): I congratulate the hon. Member for Tunbridge Wells (Mr. Norman) on his choice of subject for this debate. The issues that he has raised, although they arise from a particular situation in his constituency on which I shall comment in a moment, go much wider and are important for all people with learning disabilities and their parents, relatives and friends.
Health and social services play an important role in the lives of people with a learning disability, because many of them will rely on those services throughout their lives. We need to ensure that they are delivered in ways that are responsive to them as individuals, enabling them to develop their full potential and to be as independent as possible, yet providing appropriate support and protection for those who need it.
The hon. Gentleman raised the particular issue of the future of the Pines in his constituency. As I am sure he would acknowledge, decisions about the provision of services in a particular locality are rightly a matter for the local statutory authorities. Health and local authorities are best placed to make such decisions in the light of their knowledge of local needs and resources, taking into account departmental guidance and the needs and wishes of the local people with learning disabilities and their relatives.
I understand that West Kent health authority has no immediate plans to close The Pines. Choice Consultancy Services, which was employed by the health authority to review learning disability services in the southern part of west Kent, concluded that the service provided at The Pines in some respects fell below currently applied standards. The health authority is therefore unable to give a firm assurance at the moment that reprovision of the service at The Pines will not be considered at some time in the future. It has, however, confirmed that any possible reprovision will involve full consultation with residents and their relatives and will take account of individual needs. That is as it should be.
Services for people with learning disabilities are becoming increasingly responsive to individual needs. Many people with learning disabilities have a greater choice of living, work and leisure opportunities open to them than ever before, giving them a far better quality of life than was possible in the institutions of the past. The hon. Gentleman recognised that in his contribution.
Many health and local authorities are finding that the aspirations of people with learning disabilities and their families are changing and that what might have been acceptable forms of reprovision in the early days of hospital closures need to be replaced by even more integrated and individualised services.
I have visited services—a village community in Berkshire—and have talked to people with learning disabilities and their relatives. Many would prefer to live in ordinary houses in ordinary streets, and we need to try to respond to that wish when it is clearly expressed. Others would prefer to live in larger units or residential or village communities. It is important that, in planning and commissioning the services to be provided in any given area, health and local authorities take decisions based not on rigid ideology, but on what is best for the individuals concerned. I agree strongly with much of what the hon. Gentleman had to say on that point.
People with learning disabilities and their families have a wide range of needs and an equally wide range of views about the best ways of meeting those needs. It is therefore important that, as far as is practicable, individuals and their relatives should be offered real choices.

Mrs. Curtis-Thomas: Will my hon. Friend please clarify one point'? The hon. Member for Tunbridge Wells (Mr. Norman) mentioned financial considerations and said that running a communal home costs substantially less than furnishing an independent home in a normal street. Will my hon. Friend confirm that financial considerations are not given any notable significance in decisions about what constitutes an appropriate home for an individual?

Mr. Hutton: The Department's current guidance to authorities on developing health and social services for people with learning disabilities is quite clear on choice. It states that the aim should be
to arrange services on an increasingly individual basis, taking account of age, needs, degree of disability, the personal preferences of the individual and his or her parents or carers, culture, race and gender.
The guidance gives authorities considerable flexibility over the provision of services, including residential services. There is nothing to prevent authorities from commissioning, or providing places in, supported living arrangements, group homes, residential or village communities or indeed any other form of provision if they deem that to be appropriate. What is important is what will best meet the assessed needs and wishes of the individual and his or her relatives within the resources available.
Guidance issued in relation to the 1992 directions on choice also made it clear that there should be a general presumption in favour of people being able to exercise choice over the residential services they receive, and that accommodation should not be deemed unsuitable simply because it does not conform to the authority's preferred model of provision. That is an important point.
To help authorities decide on the most appropriate pattern of residential services for their area, the Department of Health commissioned an independent evaluation of the cost and outcomes of various forms of residential provision for people with learning disabilities. This complex research compared

dispersed housing, such as supported living and group homes, with NHS residential campuses and village communities. I hope that the results will be published later this month, and I am sure that the hon. Gentleman and my hon. Friend the Member for Crosby (Mrs. Curtis—Thomas) will read the research findings with great interest.
Residential services are not the only services used by people with learning disabilities, and the Department continues to monitor progress in implementing the guidance on learning disability services published by the previous Administration in 1992. In 1997, a national inspection of learning disability services in eight local authority areas found that significant progress had been made in developing more responsive services, such as an expanding range of accommodation, more diverse day services, employment schemes, respite care, domiciliary care services and specialist services for special groups, including those with additional disabilities.
However, the inspection also showed that, despite those significant improvements, services vary both between and within areas, and the range and quality of services currently provided for people with learning disabilities do not yet meet the needs and aspirations of users and carers. I am sure that the hon. Gentleman would agree with me that that is not acceptable. More work needs to be done if we are to provide better services in this important area.
We are taking wider initiatives, which, if I had time, I would go into in more detail. The main thrust of those initiatives, which we outlined in our White Paper "Modernising Social Services", is to raise the quality of services across the board for people with learning disabilities and for other users of social services. We want to ensure that those arrangements are properly enforced, which is why new regional care commissions will operate to national regulatory standards. I hope that that will make a significant contribution to raising the quality and consistency of services.
I hope that the hon. Gentleman welcomes the provisions in the Health Bill that will allow for closer working arrangements between the NHS and social care. Our proposals for pooled budgets, lead commissioning and integrated provision should make it easier for those two statutory authorities to work more closely together. That will be very important, and is of special relevance to services for people with learning disabilities. The provisions in the Health Bill will offer exciting new opportunities for service development.
I shall quickly deal with some of the learning disability initiatives that the Government currently have under way. One of our first steps has been to obtain a clearer picture of current services and of the progress made in implementing the guidance on learning disability services issued in 1992. Officials have studied the plans for the closure of the remaining old long-stay hospitals. To supplement the information obtained from the national inspection, we have undertaken a survey of 21 local authorities and their matching health authorities. The results, which will be published shortly, will provide much useful information to help both local and central decision making.
We have also been working to improve health services for people with learning disabilities. Last year, we published "Signposts for Success", which is good practice guidance on meeting the health needs of people with learning disabilities. That was followed up by regional workshops, and this year we have published "Once a Day", a handbook for primary health care staff. Further work in this area is planned. We are also concerned to improve the skills and competencies of front-line NHS and social care staff.
The needs of users and carers are central to all our thinking. To help us, we have set up a user group for people with learning disabilities and a learning disability advisory group, whose members include users and relatives as well as representatives of the statutory and non-statutory sectors. The groups provide an important forum in which to discuss the many issues surrounding the development of services for people with learning disabilities.
It has not been possible in the time that I have had available to go into some of the subjects to the extent that I would have liked, but I am grateful to the hon. Member for Tunbridge Wells for raising this important subject and for the way in which he couched his remarks. The Government will continue to seek improvements in the quality and responsiveness of services for people with a learning disability. In doing so, we intend to work closely with all those who share our ambition to ensure better services for that vulnerable client group. I should be happy to make sure that the hon. Gentleman is kept fully abreast of any policy developments. We are committed to a first-class NHS and first-class social care for all the people of our country. People with learning disabilities will not be left out of the process.

Question put and agreed to.

Adjourned accordingly at twenty-six minutes past Eleven o'clock.